The posting
- HRSN Authorization, Eligibility, and Medecision Administration Perform non-clinical eligibility review for HRSN services by reviewing referrals, authorization forms, member eligibility, required documentation, program criteria, and other available information. Create, update, and maintain authorizations, program records, status information, and supporting documentation in Medecision and other applicable systems. Support the build, configuration, and maintenance of HRSN prior authorization programs, workflows, queues, templates, business rules, data fields, and monitoring logic in Medecision. Apply established benefit criteria, policies, procedures, and authorization guidelines within the scope of non-clinical review; refer requests requiring clinical judgment or medical necessity review to an appropriately licensed clinical reviewer. Monitor authorization inventory, aging, due dates, and turnaround requirements; prioritize work and escalate barriers that may affect member access or compliance. Research and resolve authorization, referral, eligibility, provider assignment, and system issues affecting members, providers, and internal teams. Develop test scenarios and participate in end-to-end testing, user acceptance testing, production validation, defect resolution, and post-implementation monitoring for HRSN authorization and eligibility changes.
- HRSN Claims Processing Payment Operations Review and process HRSN claims or claim-related work items requiring manual intervention, research, correction, adjustment, or coordination in accordance with established claims processing guidelines. Verify member eligibility, benefit coverage, authorization status, provider information, dates of service, billed services, and other non-clinical information needed to support claim adjudication. Research claim edits, suspensions, denials, underpayments, overpayments, payment discrepancies, and provider inquiries using applicable claims, authorization, and reference systems. Identify coding, billing, authorization, provider setup, contract, reimbursement, and system configuration issues that may affect claim payment and route issues to the appropriate subject matter expert when outside the position's authority or scope. Coordinate with Claims Operations, Utilization Management, Provider Operations, Contracting, Finance, Information Technology, vendors, and HRSN Program staff to resolve claims and payment issues. Process approved claim corrections or adjustments within assigned authority and maintain clear documentation of research, decisions, actions, and outcomes. Monitor assigned claim inventory, aging, processing timeliness, recurring payment issues, and operational trends; communicate risks and escalate unresolved barriers. Assist with implementation and maintenance of HRSN claims processing instructions, reimbursement methodologies, desk-level procedures, and provider billing guidance. Support claim audits, payment reconciliation, root-cause analysis, implementation monitoring, and documentation needed for internal oversight and MQD review.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
#LI-Hybrid
- Bachelor's degree and four years of related experience in healthcare operations, Medicaid managed care, utilization management, prior authorization, claims processing, benefit administration, program implementation, or a related field; or an equivalent combination of education and related experience.
- Experience reviewing eligibility, referrals, authorizations, claims, benefits, provider information, or related healthcare transactions.
- Experience researching operational issues, documenting findings, and coordinating resolution across multiple business areas.
- Experience working with healthcare information systems and applying written policies, procedures, business rules, or benefit requirements.
- Working knowledge of non-clinical prior authorization administration, eligibility verification, claims processing, benefit administration, and provider billing concepts.
- Ability to apply detailed program criteria, policies, procedures, and business rules consistently while recognizing matters that require clinical, legal, compliance, coding, contracting, or other specialized review.
- Strong analytical, problem-solving, research, documentation, and organizational skills.
- Ability to manage time-sensitive inventory, establish priorities, meet quality and productivity expectations, and escalate risks appropriately.
- Ability to communicate complex authorization, claims, and system issues clearly and concisely to internal teams, providers, vendors, and program leadership.
- Ability to concurrently use multiple databases, software applications, reference materials, and online tools.
- Good working knowledge of Microsoft Office applications, including Word, Excel, PowerPoint, Outlook, and Teams.
- Ability to work accurately in claims, authorization, document management, and workflow systems and to navigate multiple applications concurrently.
- Ability to create and maintain spreadsheets, trackers, test scripts, process documentation, and operational reports.
