HRSN Authorization and Claims Analyst

HMSA•Honolulu, HI

About The Position

The HRSN Authorization and Claims Analyst performs non-clinical eligibility and authorization reviews for HRSN services, administers authorization and program records in Medecision and other applicable systems, and supports the configuration and maintenance of authorization workflows and related system functions. The role monitors authorization inventory and turnaround requirements, resolves operational and system issues, and participates in testing and implementation activities. Requests that require clinical judgment or medical necessity review are referred to an appropriately licensed clinical reviewer. The position also reviews and processes HRSN claims requiring manual intervention, verifies non-clinical claim information, researches payment issues, and processes approved corrections or adjustments within assigned authority. It coordinates resolution across internal teams and external parties, monitors claims inventory and trends, and supports claims instructions, audits, reconciliation, root-cause analysis, and oversight documentation. Other responsibilities may be assigned or directed.

Requirements

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 requiring 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 navigate multiple applications concurrently.
Ability to create and maintain spreadsheets, trackers, test scripts, process documentation, and operational reports.

Responsibilities

Perform non-clinical eligibility reviews 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, and refer matters 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.
Review and process HRSN claims or claim-related work items requiring manual intervention, research, correction, adjustment, or coordination according to 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 affecting claim payment, and route issues outside the position's authority or scope to the appropriate subject matter expert.
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 document 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.
Perform other miscellaneous responsibilities and duties as assigned or directed.