Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development.
Summary
We are seeking a talented individual for a Client Services Analyst 1 who is responsible for processing all incoming prior authorization and referral requests involving several state Medicaid members. This includes managing the intake process, referrals, eligibility verification, member demographic review and other related functions to the prior authorization or referral requests.
Your role in our mission
• 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.
• 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.
What we're looking for
• Must have experience handling prior authorization requests and referral requests (intake), medical claims, member eligibility within a healthcare setting.
• Demonstrated ability to interpret an Explanation of Benefits (EOB) and UB-04 claim form required i.e., eligibility, CPT, HCPCS, DRx codes and service types
• Familiarity with insurance payers, medical benefits, and pre-authorization processes for various healthcare services
• Must have strong understanding of Medicaid policies is a plus.
• Knowledge of ICD-10, CPT, and HCPCS codes is a plus.
• Strong data entry and documentation skills with attention to detail is required.
• Critical thinking skills to identify potential delays and resolve issues efficiently. Strong attention to data quality with a focus on data reconciliation between sources or platforms
• Strong communication skills, a positive attitude, and a friendly and professional approach to customers
• Candidates must be able to work during the prior authorization hours of 7:00 AM to 6:00 PM Eastern.
• Ability to work proficiently with Microsoft Excel, Visio, PowerPoint
What you should expect in this role
• Video cameras must be used during all interviews, as well as during the initial week of orientation.
• Full-time (40 hours a week)
• May require shift work.
• May be required to work extended hours for special business needs
• Most benefits start on first day of employment
• Remote (work from home) All USA Locations
• In order to effectively work as a teleworker with Gainwell, employees must have high speed. Greater speeds will of course provide better performance
• #LI - REMOTE
• #LI - NA1
The pay range for this position is $20.00 - $25.00 an hour, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.
Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.
