Eligibility Specialist

• Process eligibility data including new enrollments, changes, terminations, COBRA events, and dependent verifications.
• Review and reconcile eligibility files from employers, unions, and payroll systems.
• Ensure data integrity by validating input and resolving discrepancies with internal systems and external partners.
• Maintain confidentiality and security of personal and health information in accordance with HIPAA regulations.
• Respond to eligibility-related inquiries from plan participants, client HR teams, and insurance carriers via phone, email, or secure messaging.
• Support monthly and quarterly audits of eligibility data and resolve identified discrepancies.
• Coordinate with IT and system vendors to address EDI transmission or interface issues (e.g., FTP transfers, 834 files).
• Prepare reports and summaries for internal departments and clients as needed.
• Assist with open enrollment, special enrollment periods, and other eligibility-related projects.
• Stay up to date on plan changes, legal updates, and industry standards related to benefits eligibility.

Qualifications:

• 1–3 years of experience in benefits administration, eligibility processing, or a related healthcare or insurance environment.
• Experience in a third-party administrator (TPA) setting is highly desirable.
• Proficient in Microsoft Office Suite (Excel, Outlook, Word).
• Familiarity with eligibility systems and EDI file formats preferred.
• Excellent attention to detail, accuracy, and documentation.
• Strong organizational and time-management skills.
• Effective written and verbal communication skills.
• Ability to work independently and collaboratively in a team setting.
• Working knowledge of HIPAA and ERISA is a plus.
• High school diploma or GED required; Associate’s or Bachelor’s degree preferred.