Eligibility and Benefit verification

Job role

The EVBV Specialist is a dual-function role combining payer-facing operational expertise with onboarding leadership. This individual will lead eligibility verification and benefits validation workflows for oncology services assuring timely, accurate, and compliant checkswhile also mentoring new hires and driving process excellence. The role demands fluency in payer portals, EMR/RTE tools, and benefit interpretation logic, with a strong focus on cross-border coordination, audit-readiness, and patient financial clearance.

Key responsibilities

• Perform eligibility verification and benefits validation for chemotherapy, infusion, radiation therapy, diagnostics, and oncology consults. • Navigate payer portals (e.g., Availity, AIM, eviCore, Cigna, UHC) to retrieve eligibility, coverage details, and benefit limits. • Interpret clinical orders, diagnosis codes, and payer rules to ensure accurate benefit validation. • Resolve RTE issues, portal delays, and payer-specific documentation gaps. • Maintain productivity and turnaround benchmarks (e.g., verifications/day, AHT). • Escalate complex cases (e.g., dual insurance, COB, Workers Comp) with clear rationale. • Ensure compliance with protocols, payer rules, and state/federal regulations. • Lead structured onboarding for new EVBV specialists, including portal walkthroughs, SOP reviews, and shadowing. • Monitor orientation checklists and collaborate with management at 15, 45, and 90-day evaluations. • Provide expertise in EVBV workflows and recommend process improvements. • Collaborate with training teams to develop quality-focused education programs. • Attend training sessions to strengthen adult learning and mentoring strategies. • Fulfill daily responsibilities as EVBV Specialist when not assigned onboarding duties. • Exhibit professionalism, courtesy, and adherence to organizational mission, vision, and values. • Willing to provide on-site job specific training during the full orientation period as needed. • Supports and adheres to mission, vision, and values. • Exhibits professionalism and common courtesy.

Skills required

• Minimum 34 years in US healthcare eligibility/benefits workflows; oncology or high-acuity specialty preferred. • Strong understanding of payer-specific rules, coverage policies, and benefit interpretation. • Experience with RTE tools, EMR systems, and payer portals. • Familiarity with ICD-10, CPT/HCPCS, and medical necessity logic. • Excellent interpersonal, mentoring, and communication skills. • Ability to monitor performance and recommend workflow improvements. • Proficient in Microsoft Office Suite, especially Excel for tracking and reporting. • Certification in Medical Billing or RCM (AAPC, AHIMA) is a plus • Adaptability to changing environments and support for innovation • Willingness to work US shift hours and meet turnaround expectations • Effective interpersonal and communication skills. • Demonstrates positive and professional behavior in the workplace. • Ability to monitor/access performance of self, other individuals, or organization to recommend improvement in regard to work flow, processes, and procedures. • Ability to build and maintain trusting relationships. • Ability to modify strategies for different types of learning styles and offer alternative approaches in the education process. • Adapts to new and/or changing environments, supports innovation and change.