Eligibility Coordinator I

Job Summary:

The Coordinator I, Eligibility position is responsible for successful coordination of member data for both electronic and immediate manual Client Eligibility and ID Card/Booklets needs. The Coordinator I, Eligibility is responsible for ongoing testing and data integrity in the management of day to day processes and changes made to standard client Eligibility and ID Card/Booklets. This role requires knowledge of both the technical and operational sides of the business. Candidates will have direct authority to make sound business decisions with regard to client eligibility data. This role requires a working knowledge of eligibility processes, plan designs, and claims processing. The Coordinator I, Eligibility will work closely with the department Senior Manager and Supervisor to understand the interdependencies of each.

This position includes after-hour and weekend on-call duties on a rotating basis with other team members.

Job Responsibilities:

  • Is responsible for oversight of successful automated eligibility file loads to the Claim Adjudication System within specified client performance guarantee timeframes, guarding client and Navitus from potentially high dollar financial liabilities

  • Performs manual data entry of eligibility adds, terms and changes timely and accurately to prevent access to care issues that may lead to missed performance guarantees and ultimately liquidated damages

  • Reports all errors to Client contacts and/or Account Management within one business day of automated file loads

  • Requests, validates and confirms full file data feeds from Clients to ensure system integrity through audits and reconciliation, and independently assesses business needs for Navitus system improvements or recommends solutions directly to Client IT personnel using sound business judgment

  • Conducts regularly scheduled claims adjudication system release regression testing for assigned client eligibility functions and prepares a written analysis of testing/auditing results, making recommendations for corrective action and process improvement

  • Is responsible to monitor internal and external Eligibility and ID Card/Booklet data documentation and training material

  • Facilitates and/or participates in process re-design, service improvement, cost reduction, and automation, making business decisions that ensure prevention of missed client performance guarantees

  • Utilizes self-directed, sound business judgment and expertise to identify, define, formulate corrective action plans, coordinate, and validate Eligibility providing necessary detail to other departments to make claims corrections and adjustments

  • Updates all detailed work instruction documentation and communicates to all departments the nature of each process of Eligibility, COB, and ID Cards/Booklets, providing talking points for Member Services to explain changes to members and pharmacies, and Account Management to explain changes to Clients

  • Assists Coordinator IIs and Analysts with troubleshooting, root cause analysis and solution implementation for eligibility issues

  • Maintains a working knowledge of plan benefit designs and claims processing functionality

  • Is proficient with working and understanding systems

  • Other related duties as assigned/required.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled


Bachelor's degree preferred, or equivalent experience?


1-3 years of customer services experience. Knowledge of pharmaceutical eligibility, claims adjudication systems, retail pharmacy, or health insurance preferred.

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