Eligibility Processor III

Job Description

The Eligibility Processor III is responsible for administering all aspects of eligibility in Prospect’s core system (IDX), working daily pending-eligibility-verification reports from Claims, Medical Management, and Encounters Teams for eligibility verification to facilitate claims payments and encounter and referral processing, researching and verifying eligibility through multiple avenues, including health plan web portals and raw health plan eligibility files, and investigating root-cause on eligibility errors. **

Responsibilities**

• Administer all aspects of eligibility in Prospect’s core system, primarily manual edits of network affiliation and plan codes based on established processes. Maintain accuracy in working accounts within IDX and eligibility management software.
• Actively review IDX posting by Eligibility Team for accuracy. Perform regular quality control on worked accounts to proactively root out and troubleshoot issues and investigate root-cause of eligibility errors for process improvement. Perform detailed testing and quality checks on new or updated health plan file postings.
• When bandwidth is needed, place outgoing calls to providers and health plans to resolve eligibility issues. Take incoming phone calls from providers and internal departments to resolve eligibility inquiries.
• Work audit reports and daily pending-eligibility-verification reports from internal departments, including Claims, Medical Management, and Encounters, to facilitate claims payments and encounter and referral processing. Ensure that operational duties will meet or exceed all relevant stated Service Level Agreements (SLA).
• Actively participates in supporting special projects as assigned by management. Research ad-hoc eligibility issues via review of IDX postings and health plan file history.

Qualifications

Minimum Education: High School Diploma/BA, or equivalent experience. **

Minimum Experience: Three (3) years working within Eligibility for a health plan, IPA, Medical Group, or Provider Office. Experience operating PC-based software programs. Experience working with health plan eligibility files of multiple formats. Experience verifying eligibility on health plan web portals.

Req. Certification/Licensure: NONE

About Us**

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.