Eligibility Coordinator

ProCare Rx•Gainesville, GA

10d

About The Position

The Eligibility Coordinator is responsible for managing member eligibility for all new groups, assisting with client implementation, and ensuring accurate and timely information is received. This role involves enrolling and maintaining user accounts for the online management portal, processing new member enrollments and terminations, and coordinating with various departments to meet eligibility requirements. The position utilizes both manual and systematic enrollment processes, reviews daily reports for corrections, and handles incoming calls related to eligibility needs. A key aspect of the role is ensuring eligibility systems are updated daily, maintaining medical coverage files (PHI), and resolving escalated eligibility issues. The Eligibility Coordinator also performs scheduled reviews and quality assurance for member eligibility, assists with go-lives and testing data files, and handles various related duties such as member communications, personal importation, overflow phone support, and pharmacy network tasks.

Requirements

High school diploma or equivalent required.
Minimum three years experience in a customer service position, preferably as an Office Manager or a similar service position in the health care industry.
Must have excellent communication skills and the ability to work effectively with clients, pharmacies, and plan members, internal and external contacts.
Proficient PC skills in Windows-based applications.
Ability to be flexible and quickly adapt to changing needs in department.
Must be highly organized with strong attention to detail.
Must be flexible with scheduled work hours.

Nice To Haves

Post high school or specialized training in medical field desired.
Health insurance background and knowledge of pharmacy terminology desired.

Responsibilities

Coordinates the input of member eligibility for all new groups
Assists with the implementation process for new clients
Coordinates with client contacts to ensure information is received is accurate and timely
Enrolls on-line management (Portal) users and maintains accounts
Enrolls new members and/or processes terminations
Works with multiple departments to coordinate eligibility requirements
Utilizes both manual and systematic enrollment process
Reviews daily reporting for eligibility corrections
Answers incoming telephone calls related to eligibility needs
Ensures eligibility systems are updated and data is appropriately integrated on a daily basis
Maintains the eligibility files for medical coverage recipients (PHI)
Handles escalated eligibility issues to ensure problems are resolved
Ensures that all correspondence and eligibility files are properly maintained
Perform scheduled review and quality assurance for member eligibility
Assist with go-lives and testing data files
Performs various related duties as assigned including but not limited member communications, personal importation, overflow IC phone support, pharmacy network tasks; etc.