Insurance Verification & Benefits Manager

About this role

You will support the evaluation and improvement of AI systems designed to automate insurance verification, eligibility, and benefits workflows within healthcare revenue cycle operations. The role requires deep expertise in payer systems, EDI transactions, eligibility verification, benefits investigation, and front-end denial prevention. You will review AI-generated verification outputs, identify coverage or compliance errors, improve workflow accuracy, and provide structured expert feedback to help train next-generation healthcare AI systems.

Insurance Verification AI Expert

Responsibilities

• Insurance verification: Oversee eligibility determination, benefits investigation, and insurance verification across commercial, Medicare, Medicaid, and managed care payers.
• Eligibility validation: Verify patient coverage through payer portals, clearinghouses, and EDI 270/271 real-time eligibility transactions.
• Coverage issue resolution: Identify and resolve coordination-of-benefits issues, coverage gaps, and eligibility discrepancies before service delivery.
• AI output evaluation: Review and annotate AI-generated eligibility verification outputs for accuracy, completeness, and payer compliance.
• SOP development: Create and maintain standard operating procedures for eligibility and benefits verification workflows.
• KPI monitoring: Track verification accuracy, eligibility-related front-end denial rates, turnaround times, and workflow performance.
• Compliance: Ensure processes align with payer requirements, CMS guidelines, and HIPAA regulations.
• Process improvement: Identify operational gaps and recommend workflow enhancements that reduce eligibility-related denials.
• AI training support: Provide structured annotations, corrections, and expert feedback for healthcare AI training datasets.

Qualifications

• Minimum 5+ years of experience in insurance verification, eligibility and benefits management, patient access, or front-end revenue cycle operations.
• At least 2 years in a management or leadership role.
• Expert knowledge of EDI 270/271 transactions, payer portals, clearinghouses, and real-time eligibility verification tools.
• Strong understanding of Medicare, Medicaid, managed care, and commercial payer eligibility requirements and benefit structures.
• Experience resolving coordination-of-benefits issues, coverage discrepancies, and eligibility-related denials.
• Proficiency with healthcare platforms such as Epic, Cerner, Meditech, or equivalent EHR systems.
• Experience using clearinghouse platforms such as Availity, Change Healthcare, or similar solutions.
• Strong understanding of CMS guidelines, HIPAA requirements, and payer-specific verification rules.
• Exceptional written and verbal English communication skills.
• High attention to detail with the ability to identify subtle inconsistencies in patient coverage and eligibility data.
• Must be based in the United States.