Benefits Investigation & Eligibility Specialist

Job Summary

The Benefits Investigation & Eligibility Specialist verifies patient insurance eligibility and investigates benefits for genetic and molecular diagnostic testing. This role confirms active coverage, identifies patient benefit information and payer requirements, resolves missing or conflicting insurance information, and documents findings accurately so cases can move forward without avoidable reimbursement delays.

The ideal candidate is self-directed, resourceful, and able to solve problems independently while knowing when to escalate. Strong attention to detail and a patient-centered approach are required. The Specialist works with patients, provider offices, payers, and internal teams to provide clear, accurate, and timely insurance information.

Key Responsibilities

• Verify active primary, secondary, and tertiary insurance coverage; confirm member details, demographics, effective dates, plan type, payer information, and coordination-of-benefits requirements.
• Use payer portals, electronic eligibility tools, and direct payer contact to validate coverage and resolve inactive, terminated, incorrect, incomplete, or conflicting insurance information.
• Contact patients and provider offices professionally to obtain missing or corrected insurance information and escalate unresolved issues that may delay testing, billing, or reimbursement.
• Investigate patient-specific benefits for genetic and molecular diagnostic services, including deductibles, copayments, coinsurance, out-of-pocket amounts, benefit limitations, and network requirements.
• Identify prior authorization, notification, referral, medical records, and other payer requirements; route cases to the appropriate team with complete supporting information.
• Document benefit findings, payer representatives, reference numbers, call dates, portal results, and follow-up actions accurately in the designated system.
• Communicate eligibility and benefit findings clearly to patients, provider offices, and internal teams using approved language without making coverage guarantees.
• Manage assigned work queues independently, prioritize time-sensitive cases, follow up within established turnaround times, and meet productivity and quality expectations.
• Research and resolve routine issues, review work for accuracy and completeness, maintain auditable documentation, and escalate payer, system, or policy issues appropriately.
• Participate in training, quality reviews, and workflow improvements while following HIPAA, Baylor Genetics policies, and applicable payer and regulatory requirements.

Qualifications

Required

• High school diploma or equivalent.
• 2+ years of experience in healthcare insurance verification, benefits investigation, patient access, revenue cycle, or a related function.
• Working knowledge of commercial insurance, Medicare, Medicaid, and managed care plans.
• Experience using payer portals, electronic eligibility tools, and healthcare or revenue cycle systems.
• Ability to work independently, research issues, make sound decisions within established procedures, and escalate appropriately.
• Strong problem-solving skills and the ability to resolve incomplete, conflicting, or unclear insurance information.
• Exceptional attention to detail and accuracy in data entry, documentation, and follow-up.
• Strong written and verbal communication skills with a professional, patient-centered approach.
• Ability to manage multiple cases and priorities in a production-based environment.
• Ability to handle protected health information and confidential financial information appropriately.

Preferred

• Associate degree in healthcare administration, business, or a related field.
• Experience in diagnostic laboratory, genetics, molecular diagnostics, pathology, or specialty healthcare.
• Experience with Quadax, Salesforce, clearinghouses, payer portals, or similar systems.
• Familiarity with prior authorization workflows, payer medical policies, and patient financial responsibility.

Competencies

• Self-Directed Work Management
• Problem Solving & Resourcefulness
• Attention to Detail & Documentation Accuracy
• Patient-Centered Communication
• Ownership & Follow-Through
• Collaboration & Professionalism

Physical Demands and Work Environment

• Location: Remote.
• Work is primarily computer- and telephone-based and frequently requires sitting, keyboard and mouse use, speaking, listening, and reviewing electronic information.
• Regular interaction with patients, provider offices, payers, and internal operational teams.
• Protect patient, client, financial, and company information in accordance with HIPAA and Baylor Genetics policies.
• Perform other job-related duties as assigned. Reasonable accommodations will be provided in accordance with applicable law.