Eligibility Specialist I

SUMMARY: Process the full lifecycle of eligibility, enrollment, COBRA, and death benefit transactions in accordance with plan documents, written policies, administrative procedures, and applicable laws.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

1. Review, verify, and process eligibility and enrollment applications, COBRA elections, qualifying events, premium payments / refunds, and death benefit applications, ensuring accuracy, completeness, and compliance with plan rules.
2. Accurately update and maintain participant eligibility, enrollment, dependent, and benefit records in internal systems using appropriate source documentation, including changes related to employment status, marital status, dependents, disability, student status, leaves of absence, transfers, rehires, and terminations.
3. Accurately update and maintain participant eligibility, enrollment, dependent, and benefit records in internal systems using appropriate source documentation, including changes related to employment status, marital status, dependents, disability, student status, leaves of absence, transfers, rehires, and terminations.
4. Process COBRA-related activities, including verifying qualifying events, determining eligibility periods, posting payments, reviewing reports, issuing required correspondence, and updating system krecords.
5. Process death benefit claims and payments in accordance with plan provisions, including coordinating required documentation and updating participant records.
6. Review and process documents through imaging and workflow systems; annotate records as needed, request missing or additional documentation, and maintain records in compliance with retention requirements.
7. Coordinate eligibility-related updates with vendors and HMOs, including processing plan changes, adjustments, and required reporting through vendor portals and internal reports.
8. Review employer reports, premium contribution data, termination reports, and other eligibility-related submissions; reconcile discrepancies and process reimbursements or adjustments as required.
9. Provide interim or continuation benefits for participants affected by qualifying life or employment events, including maternity/paternity leave, FMLA, military leave, jurisdiction transfers, rehires, and employer contract changes, consistent with applicable laws and plan provisions.

1. Maintain a working knowledge of applicable plan documents, summaries of plan provisions, eligibility rules, and administrative policies to ensure consistent and accurate application.
2. Actively participate in system testing and implementation activities as needed.
3. Identify and recommend opportunities for process improvements related to workflow, system functionality, and administrative procedures.
4. Complete all assigned work in accordance with departmental quality, volume, and timeliness standards.
5. Coordinate and share knowledge with department staff to support cross-training, coverage, and consistent application of eligibility rules.
6. Comply with Trust Fund policies, organizational standards, HIPAA requirements, privacy and confidentiality practices, and attendance expectations.
7. Perform other related duties and special projects as assigned to support departmental and organizational needs. 

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE: 

1. High School diploma or GED required 
2. Experience in benefits administration, eligibility processing, healthcare administration, insurance, pension/benefit fund operations, or a related customer service–focused administrative role preferred
3. Ability to utilize MS Office (Excel, Word, and Outlook). Basic proficiency required.