Eligibility & Benefits Specialist

Eligibility & Benefits Specialist (RCM)

Reports To: Lead Revenue Cycle
Locations Hiring From: Arizona, Delaware, Florida, Georgia, Idaho, Indiana, Louisiana, Missouri, New Hampshire, North Carolina, South Carolina, Tennessee, Texas, Vermont, Virginia ONLY. Must currently reside and plan on residing in the entire employment.
Schedule: Monday- Friday 10-6:30pm EST
Employment Type: Full-Time
Role Overview

As an Eligibility & Benefits Specialist, you will be responsible for or verifying patient insurance eligibility and benefits, obtaining required referrals, communicating coverage and financial responsibility, and supporting accurate patient access and reimbursement. This role helps ensure patients understand their insurance benefits, estimated costs, and referral requirements while proactively identifying and resolving coverage issues before services are rendered. You will work closely with our Revenue Cycle Leads, other members of the Revenue Cycle team, and payer partners to improve the patient financial experience, reduce claim denials, and support efficient revenue cycle operations. Your attention to detail, excellent organizational skills, and commitment to customer access will contribute to the financial stability and success of Oshi as we pioneer the way in GI care.
What You'll Do: Key Responsibilities

- Verify patient insurance eligibility, benefits, authorization requirements, and referral needs prior to services.

- Obtain referrals from primary care providers and referring physicians, ensuring all referral requirements are met prior to scheduling or treatment.

- Track referral status and proactively follow up with provider offices, payers, and patients to ensure referrals are received and remain valid.

- Accurately document insurance coverage, benefit information, referrals, and eligibility details within internal systems.

- Communicate insurance coverage, patient financial responsibility, estimated out-of-pocket costs, and Oshi's billing model in a clear, professional, and empathetic manner.

- Research and resolve eligibility, coverage, referral, and insurance discrepancies that may impact patient care or reimbursement.

- Monitor eligibility verification queues, insurance changes, pending requests, and coverage updates to ensure timely resolution.

- Identify and resolve claim rejections related to eligibility, benefits, coverage, or referral issues.

- Maintain open communication with patients, providers, payers, and internal stakeholders to resolve eligibility, referral, and insurance-related questions.

- Collaborate with Billing, Accounts Receivable, Clinical Operations, and other cross-functional teams to improve patient access, billing accuracy, and reimbursement.

- Analyze eligibility, referral, and benefit verification data to identify trends, root causes, and opportunities for process improvement.

- Monitor and report on eligibility, referral, and verification metrics to support operational performance and continuous improvement.

- Contribute to workflow enhancements that improve operational efficiency, reduce claim denials, and enhance the patient financial experience.

- Ensure compliance with organizational policies, payer requirements, HIPAA, and healthcare billing and eligibility regulations.

What We're Looking For: Qualifications & Requirements
Required

- Bachelor's Degree in Business Administration or relevant course work.

- 2+ years of healthcare revenue cycle experience with a focus on eligibility, benefits, insurance verification, or patient access.

- Experience verifying insurance eligibility, benefits, authorizations, and obtaining referrals across multiple commercial and government payers.

- Hands-on experience using payer portals, Availity, and other insurance verification tools, including phone verification.

- Experience working successfully in a remote work environment with the ability to manage priorities independently.

- Proficiency with EMR and insurance verif