Eligibility Specialist Resume Sample

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Work Experience


Eligibility Specialist
05/2015 - PRESENT
Phoenix, AZ
  • Utilize and understand provider guidance and eligibility processes, in order to make necessary updates to various internal systems required for enrollment into ESI’s Prescription Drug Plan
  • Utilize and understand provider guidance and
  • Experience in a customer service setting preferably in a call center environment; Previous experience in
  • Utilize and understand provider guidance and eligibility processes, in order to make necessary updates to various internal systems required for UBC's programs
  • Assures accuracy in eligibility and enrollment processing and makes decisions in the best interest of protecting the integrity of the client’s business needs
  • Direct liaison between Broker Community, Small Business Owners, and internal Tech Team to process enrollments relating to Website functionality usability
  • ABOUT EXPRESS SCRIPTS
  • Adapt to changing environments and techniques
Eligibility Specialist, Service Center
09/2011 - 03/2015
Boston, MA
  • Utilize reasoning to make determinations
  • Learn and adhere to departmental rules, regulations, policies and procedures
  • Learn to use various computerized equipment systems
  • Use sound logic to analyze a situation and develop a viable solution
  • Quickly, accurately and efficiently enter data into a variety of automated systems
  • Maintain logs manually and electronically
  • Organize files and create and maintain documents
Senior Eligibility Specialist
07/2007 - 03/2011
San Francisco, CA
  • Be flexible, adaptable and dependable
  • Review documents for accuracy/completeness
  • Serve as first point of contact for internal clients and members during the enrollment process
  • Make outbound calls to members to gather Enrollment Data; analyze and process data accordingly
  • Handle inbound member calls and written correspondence regarding member eligibility
  • Make independent judgments in order to respond to complex or critical member issues
  • Experience in a customer service setting preferably in a call center environment
  • Work cross-functional to resolve complex client issues
  • Demonstrated ability to handle internal and external customers in a professional manner

Education


Belhaven University
2002 - 2006
Bachelor's Degree in Social Services

Professional Skills


  • Excellent verbal, written, communication and problem solving skills
  • Computer data entry and word processing skills with the ability to operate routine office equipment
  • · Active, empathetic listener with strong writing and verbal communications skills
  • Demonstrate research and problem-solving skills
  • Caseload management; schedules and timetables; effectively prioritizing; analyzing, assessing and evaluating service provisions and quality of care
  • Intermediate computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc
  • Manageable problem solving and communication skills

How to write Eligibility Specialist Resume

Eligibility Specialist role is responsible for organizational, research, software, resolve, government, insurance, flexible, clients, coaching, leadership.
To write great resume for eligibility specialist job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Eligibility Specialist Resume

The section contact information is important in your eligibility specialist resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Eligibility Specialist Resume

The section work experience is an essential part of your eligibility specialist resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous eligibility specialist responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular eligibility specialist position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Eligibility Specialist resume experience can include:

  • Strong business communication skills (telephone, e-mail, written)
  • Strong ability to communicate effectively, both orally and in writing; reading, understanding and applying rules, regulations and policies
  • Communicating effectively, both orally and in writing; reading, understanding and applying rules, regulations and policies
  • Strong attention to detail and experience working in a fast paced environment
  • Communicate effectively orally, in person and on the telephone, and in writing, with individuals at all levels, both within and outside the company
  • Relevant working experience to include 1 year of health care experience with medical insurance knowledge and terminology

Education on an Eligibility Specialist Resume

Make sure to make education a priority on your eligibility specialist resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your eligibility specialist experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Eligibility Specialist Resume

When listing skills on your eligibility specialist resume, remember always to be honest about your level of ability. Include the Skills section after experience. Present the most important skills in your resume, there's a list of typical eligibility specialist skills:

  • Strong attention to detail, strong team building skills, research and analytic skills, report preparation and documentation skills
  • Strong interpersonal skills and customer relationship skills
  • Demonstrated ability to communicate effectively with customers and co-workers, both orally and in writing, regarding complex or sensitive information or issues
  • Excellent judgment, critical thinking and decision-making skills
  • Strong communication skills to be able to assist customers navigate through the system
  • Strong organization skills and thrives under strict deadlines

List of Typical Experience For an Eligibility Specialist Resume

1

Experience For Eligibility Specialist, Service Center Resume

  • Demonstrated team lead experience desired
  • Interacting with complex and diverse eligibility issues with strong emphasis on formulating solutions and recommendations
  • Also, demonstrated success working in a team environment focused on meeting organization goals and objectives is necessary
  • Provide coaching and on-the-job training to new or experienced staff
  • Problem solving—identifies and resolves problems in a timely manner and gathers and analyzes information skillfully
  • At least six months of experience in a customer service role, interacting directly with customers either in-person or over the phone
2

Experience For Benefits & Eligibility Specialist Resume

  • 3-5 yrs work experience in insurance, reimbursement, healthcare
  • Plans, organizes and prioritizes workload and processes information at a speed necessary for successful job performance
  • Receiving calls from patients/members, gathering eligibility data
  • Assisting with completing necessary forms
  • Answering questions regarding the application process and services/benefits
  • Securing any missing verification needed
  • Working knowledge of computer programs including Microsoft Excel
3

Experience For Senior Eligibility Specialist Resume

  • Meeting with participants that are seeking childcare assistance
  • Driving to customer’s place of residence or various settings to conduct interviews and/or obtain pertinent medical documentation
  • Submitting required documents/forms
  • Maintaining superior attendance to meet the demands of the job
  • 16-22 week training program (approximately 4-6 months) combination of class room training and on the job training
4

Experience For OCM Eligibility Specialist Resume

  • Conduct timely follow up on all pending eligibility cases to ensure timely processing of accounts
  • A passion for helping others and making a difference
  • Act as a company ambassador when interfacing with clients to positively represent ESI’s vision, values, and client pledge
  • Perform other complex financial counseling functions (e.g., extended payment arrangements)
  • Meet with patients and/or representative to collect missing information and obtain signatures
5

Experience For Benefits Eligibility Specialist Resume

  • Verify demographic information on all medical records and enter insurance information into the billing system
  • Answer applicants’ questions regarding services
  • Client Focus- strives to proactively address client concerns and needs and consistently provide outstanding client service
  • · Proficient usage of Microsoft Office products including Outlook, Word, and Excel
  • Available community resources, crisis intervention, counseling, advocacy, community relationships, and referral methods
  • Fundamental principles of medical nursing services, alternatives to long term care, length of stay, pharmacology and equipment use
  • Problem-solving on complex case issues
6

Experience For HIX Eligibility Specialist Resume

  • Complete processing of new leaves and complete all daily follow-ups assigned
  • Determine eligibility and availability of leave time for each employee requesting leave for FMLA, State, and applicable Corporate protections
  • Systematic initiation of new claims in support of various Unum product types utilizing the appropriate claim adjudication system
  • Perform a policy coverage search to determine claim filing eligibility and process/triage based on standard and/or customized policy instructions
  • Participate in training/development of new staff
  • Action oriented, results driven and a team player that includes working with team members in a cross-site work environment
  • Possess an innovative mindset and is adaptable to change; ability to deal with multiple, concurrent and rapidly changing demands
7

Experience For Fa-ncaa Eligibility Specialist Resume

  • Department by providing creative analysis and judgment
  • Eligible for Telecommuting after one year of service and based on manager discretion
  • Proficiency at computer keyboarding, Outlook and Word
  • Post secondary education in accounting or related business field
  • Navigate through multiple systems simultaneously
  • Maintain accurate and complete documentation of all contacts
  • This continuously improves the process and reduces potential for legal concerns or payouts
8

Experience For Enrollment & Eligibility Specialist Resume

  • Adapt in a dynamic work environment,
  • Learns quickly, solves problems and make decisions
  • Make outbound calls to members to gather Enrollment Data
  • Analyze and process data accordingly
  • Interview the patient and/or representative by telephone to secure all demographic and financial data necessary to evaluate eligibility for medical assistance or financial assistance programs
  • Assess needs and educate patients regarding potential financial assistance eligibility and the process for application; assist patients with the completion of the financial assistance application process
  • Follow up on patients who have applied for government programs and have not submitted completed documents or forms
  • Analyze, problem solve and escalate accounts as appropriate, for potential vendor assignment
  • Conduct oversight of vendor assigned accounts and monitor performance
9

Experience For Human Services Eligibility Specialist Resume

  • Collaborate with representatives from government agencies, including state aid workers and other eligibility support agencies (i.e. HASC), and Ministry Financial Counselors to ensure speedy resolution of cases pending approval and provide any needed documentation to the agency representatives
  • Work cross-functional to resolve complex client issues; Strong project management and organizational skills
  • Experience in a customer service setting preferably in a call center environment
  • Assess and escalate as appropriate sensitive financial situations with patients, who are experiencing significant health challenges and stress
  • Perform core eligibility core function at ministry when assigned. (Excludes ministries where there is a collective bargaining agreement)
  • Schedule meet with patients and/or representative to collect missing information and obtain signatures
  • Collaborate with representatives from government agencies, including state aid workers and other eligibility support agencies (i.e. HASC), and Ministry Sr. Financial Counselors to ensure speedy resolution of cases pending approval and provide any needed documentation to the agency representatives
  • Assist with reports using MS Word, PowerPoint and MS Excel
  • Registers and interviews patients to obtain demographic and financial information necessary for patient identification, billing and collection of accounts
10

Experience For Shop Enrollment & Eligibility Specialist CSR Resume

  • Manage timelines and balance multiple deadlines; Ability to work a flexible schedule
  • Work collaboratively with Eligibility Systems Analysts, other Eligibility Associates
  • Eligibility Managers and Account Managers to provide seamless support
  • Ensure all departmental program tasks are completed timely; mentor and coach employees to ensure that best practices are circulated throughout the entire job function
  • Serve as first-line resource to identify and resolve complex and escalated cases
  • Take calls from healthcare professionals, patients, and sales representatives; provide assistance with reimbursement inquiries and conduct general payer research
  • As directed by manager conduct departmental/program team meetings to ensure team is informed of changing policies and procedures

List of Typical Skills For an Eligibility Specialist Resume

1

Skills For Eligibility Specialist, Service Center Resume

  • Excellent communication skills, both verbal and written, with the ability understand users’ questions and effectively disseminate technical information
  • One year of demonstrated public contact or customer service work; or one year of college or university experience
  • Draft unique letters and emails to customers as necessary. Use appropriate template language to communicate clearly and effectively with customers
  • One year of work related experience in a social welfare field involving determining eligibility and/or case management
  • Manage pending/incomplete prior to triage/assignment to the corresponding claims organization/team
  • Manage multiple and sometimes competing priorities, build consensus and direct teams
  • 2 years' experience working in eligibility or a related field at the health plan level
2

Skills For Benefits & Eligibility Specialist Resume

  • Previous experience working with Facets Application Software highly desired
  • Strong interactive abilities particularly when dealing with multiple departments
  • · Research and validate demographic information including Massachusetts residency, background data, immigration status, and financial information
  • Demonstrate leadership by promoting a positive team environment which results in motivated and empowered peers
  • Multi-task, with a demonstrated ability to work in a fast-paced environment handling a large volume of work
  • Demonstrated knowledge of available community resources, crisis intervention, counseling, advocacy, community relationships, and referral methods
3

Skills For Senior Eligibility Specialist Resume

  • 2-3 years previous healthcare experience with insurance verification, eligibility, and pre-authorization
  • Previous healthcare experience with insurance verification, eligibility, and pre-authorization
  • Knowledge and experience of federal/state programs such as Medicaid, SNAP, and TANF, with the ability to interpret the related laws, rules and regulations
  • Experience with MMIS, Oregon ACCESS, and data entry
  • Experience with multi-line telephone (MLT)
  • Assist providers, health plans and interal clients with eligibility inquiries, and provide excellent customer service
4

Skills For OCM Eligibility Specialist Resume

  • Strong attention to detail and ability to use complex computer system with high accuracy
  • 2~3 years Managed Care and/or HealthCare experience
  • Experience in IDX and various MCO websites
  • Skill to communicate with diverse populations in writing or orally
  • Experience in a customer service
5

Skills For Benefits Eligibility Specialist Resume

  • Advanced administrative support experience
  • Operate a computer (i.e., Microsoft Office and internet) efficiently and accurately
  • Operate various office machines (i.e., fax, copier)
  • Experience using Microsoft Office Software, Including Outlook, Word, Excel, SharePoint and PowerPoint
  • Demonstrated willingness to work long hours for several months at a time
  • Experience in Dental Field, knowledge of Dental Insurance required
  • · Genuine service-orientated individual with a commitment to effective customer service and concern for others’ needs
  • Perform complex mathematical calculations to validate customer's attestation regarding their income
  • Researching and analyzing complex rules, regulations or policies
6

Skills For HIX Eligibility Specialist Resume

  • Bring forth ideas to improve processes and materials
  • Starting salary of $28,445/year and the ability to increase salary after 12 months and again after an additional 6 months, based on performance
  • Utilizing research and analysis to make determinations, solve problems or complete work
  • Understanding of various medical interventions that pertain to the customer’s diagnosis
  • Eliciting information and gaining insights into customers and families; using a personal computer to document information
  • Reviewing case information and determining eligibility
  • Making files and doing mailings
  • Creating and maintaining databases and documents
  • Attending conferences as needed along with weekly staff meeting and events
7

Skills For Fa-ncaa Eligibility Specialist Resume

  • Assisting in special projects
  • Correct enrollment and cash posting discrepancies as they relate to billing
  • Creative and innovative thinking particularly when dealing with complex situations
  • Assists clients with obtaining required verification for determining eligibility
  • Provide exceptional customer service, ensuring that all interested parties are continually updated about the status of their account
  • Develop productive working relationships with internal and external staff
  • Problem solve by utilizing resources
  • Business English, spelling, grammar and vocabulary
8

Skills For Enrollment & Eligibility Specialist Resume

  • Ensures that all program applications submitted to HHCS are complete with supporting documentation needed to make an eligibility determination
  • Handle insurance verification and eligibility for Imaging/MRI services
  • Passion for helping community members
  • Work from a queue of office inquiries regarding any issues and/or requests
  • Participate in meetings as required.· Bring forth ideas to improve processes and materials
9

Skills For Human Services Eligibility Specialist Resume

  • Assists in all aspects of determining patient eligibility for Innovent programs (50%)
  • Assist in all aspects of enrolling eligible patients into Innovent Programs (35%)
  • Assist with reviewing patients as needed for payer and provider audits of enrolled patients. (5%)
  • Use logic and problem solving
  • · Assist applicants in gathering required documents to complete MassHealth applications
  • Conduct Title IV-E Initial and Re-determinations, re-evaluating the decision in compliance with unit specifications
10

Skills For Shop Enrollment & Eligibility Specialist CSR Resume

  • Provides voter registration forms and complies with all rules and regulations as well as state and federal codes and laws regulating public assistance programs
  • Assists clients with understanding their rights and responsibilities under the appeals process
  • Documents all hearing related information and activity in ICES and FACTS systems
  • Informs the patient of all approvals and denials of coverage, if it occurs during the patient’s hospital stay
  • Code all medical records with insurance code according to appropriate financial class

List of Typical Responsibilities For an Eligibility Specialist Resume

1

Responsibilities For Eligibility Specialist, Service Center Resume

  • Skilled in organizing work efficiently, managing multiple tasks with interruptions, as well as managing a workload with competing deadlines
  • Experience working in a team environment as well as working independently with little supervision
  • Experience working with targeted groups and with ethnically and culturally diverse populations
  • Skilled in accurately using mathematics in a work environment
  • Experience in a customer service role, interacting directly with customers either in-person or over the phone
  • Setting expectations for processes and timelines
  • Assisting providers with payment procedures and eligibility
2

Responsibilities For Benefits & Eligibility Specialist Resume

  • Ensures that confidentiality, security, and training is enforced and kept up-to-date
  • Serves as a resource to staff and the public concerning public assistance
  • In addition, working knowledge of insurance processes, denials, and insurance eligibility requirements
  • Tact and patience when dealing with individuals at all levels, both within and outside the company
  • Knowledge of health insurance correspondence denial processing
  • Knowledge of insurance rejection/denial processing to perform follow up activity
  • Serve as subject matter expert answering questions on eligibility, plan provisions and policies
  • Completes client interviews either face-to-face or via phone to re-determine eligibility for FS or TANF programs
  • Ensures case information is gathered and processed in a complete and accurate manner in accordance with State policy
3

Responsibilities For Senior Eligibility Specialist Resume

  • Enters client data into the ICES system
  • Completes client interviews either face-to-face or via phone to determine eligibility for FS, TANF, Medicaid A B or D and IMPACT programs
  • Document claims record with determination (clinical information, insured’s eligibility, provider’s eligibility, benefit approved, assessment synopsis, direction to other departments)
  • Experience working in a long term care insurance industry or evaluating Social Security Disability, Complex/Lost-Time Worker’s Compensation, or 1st/ 3rd party Liability Injury claims
  • One year of documented public contact or customer service work; or 30 semester hours from an accredited college or university in behavioral, social science, psychology, business administration, or closely related field
  • Completes client interviews either face-to-face or via phone to determine eligibility for Food Stamps and/or other Public Assistance Programs - TANF, Medicaid A B or D and IMPACT programs
4

Responsibilities For OCM Eligibility Specialist Resume

  • Input applicant data into agency’s computer systems (HIX, MA21, PACES, MMIS, etc) to establish and update customer data, validates data, and make corrections on agency computer system
  • Interview customers in-person or over the phone, and
  • Works directly with the patient or their representative to inquire about the patient’s potential eligibility for financial assistance
  • Ensures timely and accurate documentation of all notes and encounters in both nThrive’s database and the client’s database
  • Inputs applicant data into agency’s computer systems (MA21, PACES, MMIS, etc) to establish and update customer data, validates data, and make corrections on agency computer system
5

Responsibilities For Benefits Eligibility Specialist Resume

  • Verify insurance coverage eligibility for all medical records
  • Maintain integrity of the date of service batches
  • Separate and make copies of medical records for all Workers Compensation and Auto claims
  • Maintain daily/weekly/monthly production deadlines and demand
  • Give Manager new or updated insurance to add to master file
  • Interpret and explain information such as eligibility requirements, and deadlines and applicants’ legal rights
  • Excellent communication skills, both verbal and written, with the ability to understand users’ questions and effectively disseminate technical information, is essential
6

Responsibilities For HIX Eligibility Specialist Resume

  • Confidentiality- maintains the highest level of confidentiality
  • Interpersonal awareness— ability to notice, interpret, and anticipate others' concerns and feelings, and to communicate this awareness empathetically to others
  • Communication— conveys information in an effective, well organized and grammatically correct fashion. Has the ability to translate complex concepts so they are easily understood for the target audience. The ability to present your ideas clearly and articulately when speaking to individuals or groups
  • Planning/organizing—prioritizes and plans work activities, uses time efficiently and develops realistic action plans. Able to coordinate several tasks simultaneously. Has the ability to work autonomously in a fast-paced environment
  • Quality— ability to produce results that meet or exceed Milliman standards
  • Adaptability—adapts to changes in the work environment, software and systems, manages competing demands and is able to deal with frequent change, delays or unexpected events
7

Responsibilities For Fa-ncaa Eligibility Specialist Resume

  • Dependability—consistently at work and on time, follows instructions, responds to management direction and solicits feedback to improve performance
  • Access insurance carrier and/or affiliated websites
  • Obtain eligibility and benefit breakdown
  • Enter eligibility and benefit breakdown information into a central database and/or other locations
  • Report to Manager any issues, trends, and/or challenges associated with eligibility and/or benefit
  • Interact with fellow Eligibility and Benefits Team members in regards to best practices
  • Communication with Provider and Payers (10%)
  • Knowledge of email and computer usage
8

Responsibilities For Enrollment & Eligibility Specialist Resume

  • · Review and evaluate applications to determine applicant eligibility for health insurance benefits
  • · Communicate with applicants or other authorized representatives to explain programmatic requirements for all MassHealth programs
  • · Compare information provided on MassHealth applications with data from other agencies to verify initial and continued eligibility for benefits
  • · Explain appeal rights and procedures to applicants, attorneys, advocates, providers, public officials, and the general public
  • · Prepare and present explanations of eligibility determinations and represent MassHealth at appeals hearings
  • · Provide subject matter expertise as an internal resource by assisting lower level staff in interpreting policy, understanding and processing more complex/difficult eligibility cases
  • · Compile service-related statistics and special projects; prepare statistical and narrative reports to track and evaluate office performance
9

Responsibilities For Human Services Eligibility Specialist Resume

  • · Keen attention to detail; the ability to research and analyze complex financial, tax and insurance documents; capacity to assess the value of assets and income
  • · Sound judgment with an aptitude to keep composed in difficult situations
  • Reviewing medical records and interacting with customer’s family members, caregivers and/or physicians to identify and evaluate medical and psycho-social conditions
  • Medical, functional and psycho-social problems of the elderly, physically disabled and developmentally disabled children and adults
  • Establishing and maintaining effective working relationships with professional staff, caregivers, customers’ families, children and adults and with representatives of courts and various other agencies in the community
  • Solve mathematic problems accurately
  • Prepares and submits clean claims to insurance companies either electronically or by paper
  • Prepares daily reports and performs financial system maintenance as required
  • Participates in educational activities and attends monthly staff meetings
10

Responsibilities For Shop Enrollment & Eligibility Specialist CSR Resume

  • Conducts self in accordance with company’s employee manual
  • Responsible for contacting insurance companies and navigating payer websites to obtain accurate status information of outstanding claims and inputs accurate information into the computer billing system
  • Responsible for having working knowledge of payer eligibility and benefits verification/billing guidelines. Has complete understanding and working knowledge of navigating payer websites
  • Researches insurance eligibility via website or by calling the insurance company, patient, or hospital in order to resolve eligibility denials/rejections in a timely and accurate manner
  • Responsible for submitting corrected claims to appropriate payers in a timely manner if needed
  • Maintains thorough and detailed knowledge of various insurance contracts and eligibility denials and follow up guidelines

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