Eligibility and Risk Specialist

Since 1957, Shield Healthcare has provided high-quality healthcare services while focusing on customer satisfaction and employee achievement. We are dedicated to fulfilling the medical supply needs of consumers and the caregiving community while maintaining a 99% overall customer satisfaction rating. Over the years, Shield HealthCare has expanded nationally with current service locations in California, Colorado, Illinois, Ohio, Texas and Washington.

Shield HealthCare is looking for an Eligibility and Risk Specialist in Valencia, CA responsible for verifying eligibility and risk delegation for health plan members and properly maintaining customer records. Research related rejections and denials and make the necessary corrections to meet billing guidelines or recommend claims for write-off.

This position is on-site in Valencia, CA.

JOB RESPONSIBILITIES:

• Responsible for verifying eligibility and risk delegation for health plan members and properly maintaining the customer records
• Ensure that all eligibility verification requests are completed in a timely manner
• Research problems and find solutions to eligibility related claim rejections and denials
• Inform management of changes or trends with eligibility and risk issues
• Research denials and billing requirements of third-party carriers utilizing web portals, phone contact, EOBs, provider manuals, etc.
• Adjudicate claims issues by preparing and submitting corrected claims or appeals
• Recommend claims for write-off when billing requirements are not met
• Effectively communicate by phone, email, and in-person with third-party payers and internal staff to resolve eligibility issues and establish positive relationships
• Accurately update and notate accounts receivable system, collections notepad, and customer accounts
• Remain updated on company policies and procedures and third-party payer guidelines, bulletins, and billing requirements
• Work reports and projects assigned by management
• Ensure appropriate follow-up and timely completion of assignments

QUALIFICATIONS:

• Familiarity with various medical insurance payer guidelines/billing requirements preferred
• Proficiency in Microsoft Office with experience working in Microsoft Excel
• Must be detail oriented, thorough, accurate, and organized
• Proven ability to research and solve problems
• Good written and verbal communication skills

Pay & BENEFITS:

• $19-20 / hour
• Medical, Dental, and Vision
• 401(k) with Company Match
• Sick and Vacation Days
• Flexible Spending Account
• Life & Disability Insurance
• Education Assistance
• Employee Referral Program

Career-minded individuals will find our business challenging and our reputation for excellence just one of the rewards we have to offer. To further enhance this tradition of excellence, our employees participate in continuous training and development programs in a variety of disciplines.