Processing all incoming prior authorization and referral requests involving several state Medicaid members
Managing the intake process, referrals, eligibility verification, member demographic review and other related functions to the prior authorization or referral requests
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 HIPPA compliance

High School Diploma or GED required
Minimum of 3 years of client service experience
Healthcare industry experience preferred
Exposure to SQL Server, reporting tools, or business intelligence platforms (e.g., Tableau) preferred
Strong analytical skills with the ability to apply logic and structured processes to resolve work-related issues and identify improvement opportunities
Ability to develop and translate client-specific processes between technical and non-technical stakeholders
Demonstrated attention to data accuracy and quality, including experience reconciling data across multiple systems or platforms

Client Services Analyst I

Key skills