Exception Template

Job Summary We are seeking a detail-oriented and highly motivated Claims Authorization Specialist to join our fast-paced healthcare operations team. In this role, you will be responsible for investigating, reviewing, and resolving claims that have been suspended (pended) due to missing or invalid prior authorizations. You will support multiple lines of business—including Medicaid, Dual-Eligible (Duals), and Health Insurance Marketplace—while navigating complex, state-specific guidelines to ensure accurate and compliant claims processing. Key Responsibilities Claims Research & Resolution: Conduct in-depth research on claims pended for lack of authorization. Cross-Functional Collaboration: Provide clear, accurate instructions and directives to the Corporate Claims Team to facilitate the appropriate release and processing of pended claims. Case Management: Review, manage, and resolve escalated authorization issues and cases within the internal care management and ticketing systems. Regulatory Compliance: Interpret and apply challenging, state-specific guidelines and business rules to ensure claims are adjudicated accurately and within compliance standards. Workflow Optimization: Continuously monitor designated authorization reports and queues to ensure timely turnaround and prevent processing backlogs. Qualifications & Experience Experience: 1 to 2 years of prior experience in healthcare claims processing, with a specific focus on prior authorizations and resolving pended claims (highly preferred). Industry Knowledge: Solid understanding of Medicaid, Duals, and Marketplace health insurance products and billing practices. Analytical Skills: strong problem-solving abilities with the capacity to navigate complex state rules and unique regulatory guidelines. Attention to Detail: High level of accuracy in reviewing data and providing processing instructions.

salary: $26.99 - $27 per hour
shift: First
work hours: 8 AM - 5 PM
education: High School

Responsibilities

Claims Research & Resolution: Conduct in-depth research on claims pended for lack of authorization.
Cross-Functional Collaboration: Provide clear, accurate instructions and directives to the Corporate Claims Team to facilitate the appropriate release and processing of pended claims.
Case Management: Review, manage, and resolve escalated authorization issues and cases within the internal care management and ticketing systems.
Regulatory Compliance: Interpret and apply challenging, state-specific guidelines and business rules to ensure claims are adjudicated accurately and within compliance standards.
Workflow Optimization: Continuously monitor designated authorization reports and queues to ensure timely turnaround and prevent processing backlogs.

Skills

• Intermediate to advanced Amisy
• Basic TuCare
• Basic CenPas

Qualifications

• Years of experience: 1 year
• Experience level: Experienced

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Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact [email protected].

Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).

This posting is open for thirty (30) days.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.