Claims Reimbursement and Eligibility Specialist

Job Description

Job Description

Position Overview:

We are seeking a detail-oriented and analytical Reimbursement and Eligibility Specialist to join our team. This position is responsible for reviewing, processing, and reconciling insurance claims to ensure accurate and timely reimbursement for services rendered. The ideal candidate has a strong understanding of healthcare billing, insurance guidelines, and claims resolution processes, particularly within a behavioral health or mental health setting.

Key Responsibilities:

Claims Review & Processing

• Review and analyze insurance claims for accuracy, completeness, and compliance with payer requirements.

• Submit claims to insurance companies and third-party payers via electronic and/or paper submissions.

• Monitor claim status and follow up on unpaid, denied, or rejected claims to ensure timely resolution and reimbursement.

• Identify trends in claim denials and collaborate with billing, coding, and clinical teams to resolve issues and prevent future occurrences.

Reconciliation & Reporting

• Reconcile payments, adjustments, and denials with Explanation of Benefits (EOBs) and remittance advice.

• Work with accounts receivable staff to ensure accurate posting and timely follow-up on outstanding balances.

• Generate and analyze claims-related reports to monitor key metrics (e.g., denial rates, aging reports, reimbursement trends).

• Assist with month-end close processes by providing claims data and documentation as needed.

Compliance & Documentation

• Ensure all claim submissions and processes comply with HIPAA, payer regulations, and internal policies.

• Maintain detailed documentation of claims activity, communication with payers, and resolution efforts.

• Assist in audits and provide documentation for internal and external reviews.

Qualifications:

• Associate’s or Bachelor’s degree in Healthcare Administration, Business, or a related field preferred.

• 2+ years of experience in medical billing or claims analysis, preferably in a mental health or behavioral health setting.

• Strong knowledge of insurance billing procedures, payer rules, CPT/ICD-10 coding, and medical terminology.

• Familiarity with EHR and billing systems (e.g., Kareo, Athena, NextGen, or similar platforms).

• Proficient in Microsoft Excel and other office software.

• Excellent attention to detail, analytical thinking, and organizational skills.

• Strong communication and problem-solving abilities.

Work Environment & Schedule:

• This is a full-time, in-office position.

• Standard hours are Monday through Friday, 8:00 AM – 4:30 PM.

• Some flexibility may be required during billing cycles or month-end close.