Eligibility and Benefits Manager – US Healthcare RCM

Eligibility and Benefits Manager – US Healthcare RCMPosition OverviewThe Eligibility and Benefits Manager will oversee and optimize the eligibility verification, benefits coordination, claims submission, and remittance processes within the Revenue Cycle Management (RCM) framework. This role ensures compliance with HIPAA standards, accuracy in patient coverage validation, and seamless communication between providers and payers using EDI transactions.Key ResponsibilitiesEligibility Verification (EDI 270/271):Manage and monitor eligibility inquiries (270) to confirm patient insurance coverage before service.Interpret eligibility responses (271) to ensure accurate benefit details, including co-pays, deductibles, and coverage limits.Implement automated workflows to reduce eligibility-related denials.Claims Management (EDI 837):Oversee submission of healthcare claims (837P, 837I, 837D) to payers.Ensure compliance with payer-specific companion guides and coding standards (ICD-10, CPT, HCPCS).Validate claim accuracy to minimize rejections and expedite reimbursements.Payment & Remittance (EDI 835):Review and reconcile Electronic Remittance Advice (ERA) files.Ensure proper posting of payments, adjustments, and denials into practice management systems.Collaborate with finance teams to resolve discrepancies and improve cash flow.Compliance & Audit:Maintain HIPAA compliance across all EDI transactions.Develop audit trails and reporting mechanisms for dispute resolution and compliance reviews.Train staff on eligibility and benefits processes, ensuring operational excellence.QualificationsBachelor’s degree in Healthcare Administration, Business, or related field (Master’s preferred).10+ years of experience in US Healthcare RCM, with strong expertise in eligibility and benefits management.Hands-on experience with EDI transactions (270, 271, 837, 835).Knowledge of payer rules, coding standards, and HIPAA regulations.Strong analytical, communication, and leadership skills.Desired CompetenciesTechnical Expertise: Proficiency in EDI systems, clearinghouses, and practice management software.Operational Excellence: Ability to streamline workflows and reduce eligibility-related denials.Compliance Focus: Deep understanding of HIPAA and payer-specific requirements.Leadership: Capability to train, mentor, and lead RCM teams effectively.#EligibilityManager #BenefitsVerification #HealthcareRCM #EDI270 #EDI271 #EDI837 #EDI835 #RevenueCycleManagement #USHealthcare #ComplianceLeadership

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