HRSN Authorization and Claims Analyst

HMSA; Honolulu (HI); Hybrid; USD 59,000 - 116,000; Full time

Job summary

HMSA in Hawaii seeks a HSRN Authorization and Claims Analyst for a hybrid role. You will manage non-clinical eligibility, authorizations, and claims processing support to ensure accurate and timely payments in line with MQD requirements and HMSA policies.

The role builds and maintains prior authorization programs and workflows, reviews referrals and documentation, and coordinates resolution of authorization, billing, and payment issues. Strong analytical and communication skills are essential.

Qualifications

• Bachelor's degree or equivalent with 4+ years in healthcare operations, Medicaid managed care, utilization management, prior authorization, or related fields.
• Experience reviewing eligibility, referrals, authorizations, and claims.
• Experience researching operational issues and coordinating resolutions.
• Familiarity with healthcare information systems and policy procedures.
• Knowledge of non-clinical prior authorization, eligibility verification, and claims processing.

Responsibilities

• Perform non-clinical eligibility review for HRSN services, reviewing referrals, authorizations, member eligibility, and required documentation.
• Create, update, and maintain authorizations and program records in Medecision and other systems.
• Support build and maintenance of HRSN prior authorization programs, workflows, and business rules.
• Apply benefit criteria and policies; refer clinical decisions to licensed reviewers.
• Monitor authorization inventory, aging, and due dates; escalate barriers to member access.
• Research and resolve authorization, eligibility, and system issues affecting members and providers.
• Develop test scenarios and participate in user acceptance testing and validation.

Skills

Analytical thinking

Documentation

Communication

Time management

MS Office proficiency

Education

Bachelor's degree

4+ years healthcare ops experience

Tools

Medecision

Claims processing systems

Data analysis tools

Job description

Hybrid Work Environment - Must reside in Hawaii**

Employment Type

Full-time

Exempt or Non-Exempt

Exempt

Job Summary

Hybrid Work Environment - Must reside in Hawaii**

Pay Range

$59,000 - $116,000, position is eligible for an incentive bonus

Note

Individuals typically begin between the minimum to middle of the pay range

The HSRN Authorization and Claims Analyst supports the administration of Health-Related Social Needs (HRSN) benefits under Hawai'i's QUEST Integration Section 1115 Demonstration. The position performs a balanced combination of non-clinical eligibility and authorization administration and claims processing support to help ensure HRSN services are authorized, adjudicated, and paid accurately and timely in accordance with Med-QUEST Division (MQD) requirements, benefit design, and HMSA policies and procedures.

The position supports the build and maintenance of prior authorization programs and workflows in Medecision; reviews referrals and supporting documentation for non-clinical eligibility; processes or researches HRSN claims; and coordinates resolution of authorization, billing, and payment issues. The analyst also translates program requirements into business rules, data requirements, and test scenarios and participates in user acceptance testing and implementation validation for HRSN system changes.

Minimum Qualifications

• 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 escalade 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.

Duties And Responsibilities

• 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 escalates 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 escalates 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.