State Operations Coverage Specialist

Patient Funding Alternatives; Woburn (MA); On-site; USD 42,000 - 60,000; Full time

Benefits offered by this job

Medical coverage

Dental and vision

401(k) retirement plan with company-m

Job summary

Patient Funding Alternatives (PFA) seeks a State Operations Coverage Specialist to support the Pennsylvania team, assuring services and medications are in-network and resolving coordination of benefits issues to help families obtain necessary care.

The role requires strong problem-solving, meticulous attention to detail, and deep knowledge of Pennsylvania Medicaid and the PA HIPP program, with a collaborative team environment and structured responsibilities.

Qualifications

• High school diploma or GED with healthcare-related coursework or training.
• 2+ years in insurance verification, prior authorization, Medicaid or managed care, or pharmacy benefits.

Responsibilities

• Verify services, providers, and medications are in-network for ESI and Medicaid.
• Coordinate benefits issues and obtain prior authorizations as needed.
• Support team meetings and perform other duties as required.

Skills

Attention to detail

Problem solving

Verbal and written communication

Education

High school diploma or GED

Healthcare administration coursework

Bachelor’s degree (preferred)

Job description

About Patient Funding Alternatives (PFA)
At Patient Funding Alternatives (PFA), we remove the barriers that keep Medicaid-eligible and medically underserved people from getting the care they deserve. We partner with hospitals and health systems across the country to help patients secure coverage through employer-sponsored insurance, which simplifies the process for the patient, protects them financially, and improves outcomes for the hospital.

We are the only organization in the U.S. offering a full Premium Assistance Enrollment service supported by dedicated Patient Advocates working on-site inside partner hospitals.

PFA is growing quickly nationwide, and that growth rests on people who care about the patients in front of them. We believe our employees are our most valuable resource, and we work hard to protect a real work/life balance inside a culture built on empathy, teamwork, and respect.

Job Description

Position Summary

The State Operations Coverage Specialist handles day-to-day operational work in support of PFA's Pennsylvania team. The role confirms that the services, providers, and medications families need are in network, and solves coordination of benefits issues so families can get the care and medications they need.

Success in this role takes strong problem-solving, close attention to detail, and a willingness to build deep knowledge of Pennsylvania Medicaid and the PA HIPP program.

Key Responsibilities

• Confirm that all services, providers, and medications are in network with both Employer-Sponsored Insurance (ESI) and Fee-for-Service (FFS) Medicaid.

Coordination of Benefits & Problem-Solving (45%)

• Resolve coordination of benefits issues.
• Help families obtain prior authorizations as needed.
• Resolve pharmacy issues and help families obtain medications as needed.

Team Support & Other Duties (10%)

• Participate in team meetings and complete follow-ups.
• Perform other duties as needed.

Qualifications

Required Qualifications

Education

• High school diploma or GED, and completion of formal training or coursework in healthcare administration, patient services, or a similar field.
• At least 2 years of experience in insurance verification, prior authorization, Medicaid or managed care, pharmacy benefits, or revenue cycle.

Preferred Qualifications

• Bachelor's degree in healthcare administration, patient services, or a related field.
• 3 to 5 years of experience in insurance verification, prior authorization, Medicaid or managed care, pharmacy benefits, or revenue cycle, ideally with Pennsylvania Medicaid or the PA HIPP program.
• Extensive knowledge of Pennsylvania Managed Care Medicaid, Medical Assistance, and the PA HIPP program.
• Extensive knowledge of obtaining prior authorizations.

Core Skills & Competencies

Technical Skills

• Ability to read and analyze drug formularies and Summary of Benefits documents.

Interpersonal & Organizational Skills

• Excellent verbal and written communication skills.
• Effective time management, organizational skills, and attention to detail.
• Creative problem-solving skills.

Additional Information

At PFA, we invest in your total well-being. You'll have access to a comprehensive benefits package that includes employer-subsidized medical coverage, supported by a supplemental cost-offset benefit that helps reduce your out-of-pocket expenses at the point of care. Additional benefits include dental and vision coverage, company-paid life and disability insurance effective day one, a 401(k) retirement program which includes up to a $2,000 annual match, flexible spending accounts, an Employee Assistance Program, and a wellness benefit, all designed to support you and your eligible dependents from the moment you join our team.

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