Encounter Operations Eligibility Specialist - Remote

at  Homeland LLC

JOB SUMMARY

Homeland has partnered with a leading provider of employee benefits, specializing in dental health coverage for millions across the U.S. Our client is seeking an Encounter Operations Eligibility Specialist to join their team.
The Encounter Operations Eligibility Specialist is responsible for resolving member eligibility-related rejections from Medicaid and Medicare encounter submissions to clients and states. This role includes re-adjudicating claims and ensuring timely resubmission. As part of a high-performing team, the specialist helps meet contractual obligations and minimize financial risks through collaboration and process improvement.
Success requires high performance, humility, and a passion for improving lives. In this role, the specialist will process dental, vision, and hearing claims in accordance with policies, utilizing company systems and resources. Responsibilities include maintaining a 98% processing quality, handling a minimum of 150 rejects per day, and possessing knowledge of ICD-10, ADA, and CMS standards.

Responsibilities

• Understand contracts, performance requirements, and claims processing/payment process for encounter submission
• Experience with CDT, CPT, and HCPCS codes
• Conduct reviews and adjustments of claims due to rejections on encounter claims, following Dental/Vision/Hearing plan guidelines
• Handle difficult or non-routine claims and special projects
• Monitor and manage encounter rejections from multiple sources
• Research, track, and trend issues to improve encounter submission processes
• Test and implement system changes and updates in collaboration with the IT Department
• Possess thorough knowledge of diagnostic and procedural coding for vision, hearing, and dental terminology
• Skilled in using systems and applications for claims adjudication and research of provider and member data
• Ensure timely and accurate processing of dental, vision, and hearing claims within contractual and regulatory time frames
• Apply policies and procedures to confirm claims meet payment criteria as per contractual guidelines
• Attend team meetings related to encounter processing and updates on encounter submissions
• Maintain effective intradepartmental communications through sharing plans, regular departmental meetings, and informal interactions
• Contribute to team efforts by taking on additional responsibilities as needed

Requirements

• High School Diploma or equivalent required
• Proficiency in Microsoft applications and/or Windows-based tools (Outlook, Excel, Word) required
• 1-2 years of insurance claims experience required
• Must maintain internet service for remote work; minimum speeds of 50 Mbps download and 10 Mbps upload are required when hardwired and not on a VPN
• Associate’s Degree or a minimum of 2 years’ experience in a related field, preferred
• Experience with standard EDI file formats and protocols (e.g., 837P, 837D, 835, 834, 277, 999), preferred

SUMMARY

Apply today!
EEO Notice
Homeland LLC is an Equal Opportunity Employer. Homeland LLC provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state, and local laws. Homeland LLC complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. Reasonable accommodation is available for qualified individuals with disabilities, upon request

• Understand contracts, performance requirements, and claims processing/payment process for encounter submission
• Experience with CDT, CPT, and HCPCS codes
• Conduct reviews and adjustments of claims due to rejections on encounter claims, following Dental/Vision/Hearing plan guidelines
• Handle difficult or non-routine claims and special projects
• Monitor and manage encounter rejections from multiple sources
• Research, track, and trend issues to improve encounter submission processes
• Test and implement system changes and updates in collaboration with the IT Department
• Possess thorough knowledge of diagnostic and procedural coding for vision, hearing, and dental terminology
• Skilled in using systems and applications for claims adjudication and research of provider and member data
• Ensure timely and accurate processing of dental, vision, and hearing claims within contractual and regulatory time frames
• Apply policies and procedures to confirm claims meet payment criteria as per contractual guidelines
• Attend team meetings related to encounter processing and updates on encounter submissions
• Maintain effective intradepartmental communications through sharing plans, regular departmental meetings, and informal interactions
• Contribute to team efforts by taking on additional responsibilities as neede