Client Services Analyst I (Fully Remote - USA)

Gainwell Technologies LLC • OH

89d • $35,900 - $51,300

About The Position

We are seeking a talented individual for a Client Services Analyst 1 who is responsible for processing all incoming prior authorization and referral requests involving several state Medicaid members. This includes managing the intake process, referrals, eligibility verification, member demographic review and other related functions to the prior authorization or referral requests.

Requirements

• Experience in processing prior authorization and referral requests, handling medical claims, and verifying member eligibility in a healthcare setting.
• Proficient in interpreting Explanation of Benefits (EOB) and UB-04 claim forms, with working knowledge of CPT, HCPCS, DRx codes, and service types.
• Familiarity with insurance payers, medical benefits, and pre-authorization procedures; understanding of Medicaid policies and medical coding (ICD-10, CPT, HCPCS) is a plus.
• Strong analytical and critical thinking skills to identify delays, resolve issues, and ensure data accuracy and reconciliation across systems.
• Excellent communication skills with a professional, customer-focused approach; ability to work effectively within a team and independently.
• Proficient in Microsoft Excel, Visio, and PowerPoint; must be available to work during prior authorization hours (7:00 AM – 6:00 PM Eastern Time).

Responsibilities

• Ensures correct prior authorization/referral form is completed for patient’s plan.
• Reviews medical necessity documents for accurate information to include patient provider identification information, clinic or procedure requested, and appropriate CPT/Diagnosis codes to verify the accuracy and completeness of information submitted by healthcare providers.
• Ensures diagnoses, procedures, and services are correctly documented, in accordance with industry standards and regulatory requirements.
• Validates the appropriateness of prior authorization requests and referrals based on established policies, contracts, and medical guidelines.
• Identifies discrepancies or inconsistencies and appropriately communicate them for further investigation.
• Monitors prior authorization requests and referrals processing activities to ensure adherence to legal and regulatory requirements, such as HIPAA, CMS guidelines, and contractual obligations.
• Updates systems with patient information and actions to ensure timely claims payment.
• Achieves daily, monthly, and quarterly quality and productivity KPIs.
• Secures patient demographics and medical information, ensuring HIPAA compliance.

Benefits

• Generous, flexible vacation policy
• 401(k) employer match
• Comprehensive health benefits
• Educational assistance
• Leadership and technical development academies

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Number of Employees: 5,001-10,000 employees