Eligibility Specialist

Pinnacle Home Care • Oldsmar, FL

1d

About The Position

Pinnacle Home Care, Florida’s largest independent Medicare-certified home health provider, is seeking an Eligibility Specialist to join their award-winning team. This role involves verifying patient insurance eligibility and benefits, resolving insurance issues, and maintaining accurate patient records to ensure smooth operations in patient care, authorization, billing, and reimbursement. The specialist will collaborate with internal teams and external payer representatives, adhering to strict confidentiality and regulatory requirements while meeting productivity and quality standards.

Requirements

• High school diploma or GED required.
• Minimum of one (1) year of healthcare, medical billing, insurance verification, eligibility, or related experience required.

Nice To Haves

• Experience verifying insurance eligibility and benefits preferred.
• Experience in home health or another healthcare setting preferred.
• Experience working with electronic medical records and payer portals preferred.
• Previous experience with Medicare, Medicaid, managed care, commercial insurance, or other healthcare payer systems preferred.
• Previous home health experience preferred.
• Experience with WellSky or similar healthcare information systems preferred.
• Knowledge of insurance eligibility, benefits, deductibles, copayments, coinsurance, and coverage limitations preferred.

Responsibilities

• Verify patient insurance eligibility and benefits for new, returning, and existing patients within established departmental timeframes.
• Review and resolve insurance eligibility issues identified in WellSky and other applicable systems.
• Process and update insurance changes, payer information, and related demographic or coverage information as required.
• Accurately document eligibility and benefit information in the patient record, including, when applicable: Effective and termination dates of coverage, primary and secondary insurance information, copayments and deductibles, coinsurance, benefit limitations, coverage requirements, out-of-network considerations, other payer-specific requirements that may affect services or reimbursement.
• Communicate eligibility changes, discrepancies, or coverage concerns to the appropriate branch and internal departments in a timely manner.
• Identify potential eligibility, coverage, or payer-related issues that could affect patient services, authorizations, billing, or reimbursement and escalate them.
• Collaborate with the Eligibility Team Lead and Authorization Manager regarding complex eligibility matters, unresolved discrepancies, payer requirements, and issues requiring escalation.
• Communicate professionally and effectively with patients, insurance companies, payer representatives, branch personnel, and internal departments to obtain and clarify insurance information.
• Respond to eligibility-related inquiries and work toward timely resolution of identified concerns, discrepancies, or account issues.
• Maintain accurate and complete documentation of eligibility verification activities and communications in the appropriate systems.
• Meet established productivity, accuracy, quality, and turnaround-time expectations for the position.
• Monitor assigned accounts and follow up on outstanding eligibility issues within established departmental timeframes.
• Maintain confidentiality and comply with HIPAA and all applicable privacy and security requirements when handling protected health information.
• Follow Pinnacle Home Care policies, procedures, standards of conduct, attendance requirements, and applicable regulatory requirements.
• Participate in training, staff meetings, quality initiatives, and process-improvement activities as assigned.
• Perform other related duties and responsibilities as assigned by the Eligibility Team. Lead, Authorization Manager, or other authorized member of management accountability and Performance Expectations.
• Completing assigned eligibility verification and follow-up activities accurately and within established timeframes.
• Maintaining accurate and complete patient insurance information and identifying and escalating eligibility concerns that may affect patient care, authorization, billing, or reimbursement.
• Maintaining appropriate communication with internal departments and external payer representatives.
• Meeting established productivity, quality, accuracy, and turn around-time standards, protecting confidential patient and company information, following all applicable Pinnacle Home Care policies and procedures and regulatory compliance.

Benefits

• Personalized, One-on-One Care
• Growth & Stability
• Ongoing Professional Development: Free Continuing Education Units (CEUs) to support licensure and career advancement.
• Competitive Benefits & Perks: Including an employee referral program where you can earn rewards.
• Recognized Excellence: Ranked as a USA Today Top Workplace.
• Flexible Scheduling
• Supportive & Fun Culture

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED