HRSN Authorization and Claims Analyst

Hawaii Medical Service Association•Honolulu, HI

About The Position

The HRSN Authorization and Claims Analyst performs non-clinical eligibility and authorization administration for HRSN services, including reviewing referrals, authorization forms, member eligibility, required documentation, and program criteria. The role maintains authorizations and program records, supports configuration and maintenance of HRSN prior authorization programs and workflows in Medecision, monitors authorization inventory and turnaround requirements, researches operational issues, and participates in testing and implementation activities. Requests requiring clinical judgment or medical necessity review are referred to an appropriately licensed clinical reviewer. The position also reviews and processes HRSN claims or claim-related work items requiring manual intervention, research, correction, adjustment, or coordination. It verifies non-clinical information needed for claim adjudication, investigates payment and claim issues, coordinates resolution with internal teams and external parties, processes approved adjustments within assigned authority, and maintains documentation. The analyst monitors claims inventory and trends, supports claims procedures and provider guidance, and assists with audits, payment reconciliation, root-cause analysis, implementation monitoring, and MQD review 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 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.

Responsibilities

Review referrals, authorization forms, member eligibility, required documentation, program criteria, and other available information for non-clinical HRSN eligibility review.
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 matters requiring clinical judgment or medical necessity review to a 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 in accordance with established 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 matters 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 for internal oversight and MQD review.
Perform other miscellaneous responsibilities and duties as assigned or directed.