Insurance Eligibility Specialist

PRESTIGE HEALTHCARE RESOURCES INC • Washington, DC

18d

About The Position

Prestige Healthcare Resources, Inc. (PHRI) is a leading behavioral healthcare organization dedicated to improving the lives of individuals and families across the District of Columbia. We provide high-quality, person-centered services and rely on accurate insurance verification to ensure our Consumers receive timely access to care without disruption. The Insurance Eligibility Specialist plays a vital role at the front end of service delivery and billing accuracy. By ensuring all Consumers have active insurance coverage and resolving eligibility issues proactively, this position directly supports service continuity, organizational compliance, and reimbursement integrity. As the Insurance Eligibility Specialist, you will be responsible for verifying and maintaining accurate insurance information for all new and existing Consumers across all PHRI programs. You will prevent disruptions in care, support billing operations, and ensure compliance with payer and regulatory standards.

Requirements

• High school diploma or equivalent required; Associate’s or Bachelor’s degree in healthcare administration, business, or related field preferred.
• 1–2 years of experience in insurance verification, eligibility determination, or medical billing within healthcare or behavioral health.
• Strong knowledge of DC Medicaid, Medicare, MCOs, and commercial insurance highly preferred.
• Experience using EHR systems and Microsoft Office Suite.
• Exceptional attention to detail and accuracy in data entry and documentation.
• Strong communication and customer service skills.
• Ability to handle confidential information with professionalism.
• Ability to work independently and collaboratively within multidisciplinary teams.

Responsibilities

• Verify insurance eligibility for all new Consumers.
• Conduct ongoing reverification for existing Consumers according to agency timelines.
• Confirm coverage through payer portals, clearinghouses, and verification tools.
• Identify benefit limitations and prior authorization requirements and notify appropriate staff.
• Maintain accurate, up-to-date payer information within the EHR.
• Process and document payer changes promptly and accurately.
• Track and address upcoming coverage expirations or lapses.
• Document all verification actions per DC MHRS and HIPAA standards.
• Contact Consumers to obtain missing information or resolve insurance discrepancies.
• Provide guidance on enrollment, reinstatement steps, or coverage issues.
• Help Consumers understand payer rules affecting service access.
• Work closely with intake, clinical, billing, and administrative teams.
• Notify staff promptly when insurance issues impact service eligibility or billing.
• Collaborate with billing teams to minimize denials related to eligibility errors.
• Research and resolve eligibility discrepancies with payers.
• Escalate complex eligibility cases as needed.
• Assist billing staff with claim denials related to insurance eligibility.
• Adhere to DC MHRS, Medicaid/MCO, and agency standards.
• Generate eligibility status reports and summaries of unresolved issues.
• Ensure documentation is audit-ready for internal or external reviews.
• Monitor payer policy changes and share updates with relevant staff.
• Recommend workflow enhancements to strengthen accuracy and efficiency.
• Participate in ongoing training and system updates related to insurance verification.

Benefits

• Impactful work: Your accuracy ensures Consumers can access uninterrupted behavioral health services.
• Strong team environment: Work closely with intake, billing, and clinical teams in a collaborative, supportive atmosphere.
• Professional growth: Opportunities to deepen expertise in insurance, compliance, Medicaid/MCO processes, and behavioral health operations.
• Mission-focused organization: Join a company committed to empowering individuals and improving community well-being.
• Operational excellence culture: Your contributions directly support compliance, reimbursement integrity, and high-quality care delivery.

What This Job Offers

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