Authorizations and Eligibility Specialist

Position Summary:

SarahCare, a leader in home care services, is seeking a Home Care Authorizations and Eligibility Specialist to ensure all client authorizations and eligibility requirements are accurately maintained and in compliance with state and Managed Care Organization (MCO) guidelines. This role involves conducting thorough research and investigation, communicating with various agencies, and collaborating with internal teams to resolve authorization or eligibility issues promptly and efficiently.

Key Responsibilities:

1. Authorization and Eligibility Management:

◦ Verify and maintain accurate client authorizations and eligibility for home care services.

◦ Regularly review and update records to ensure compliance with MCO and state requirements.

2. Research and Investigation:

◦ Conduct in-depth investigations into authorization and eligibility discrepancies.

◦ Identify and address root causes of authorization denials or delays.

3. Communication with External Stakeholders:

◦ Liaise with Managed Care Organizations (MCOs), Pennsylvania’s Office of Long-Term Living (OLTL), and County Assistance Offices (CAOs) to resolve authorization and eligibility issues.

◦ Submit required documentation and follow up on outstanding cases to secure approvals.

4. Collaboration with Internal Teams:

◦ Work closely with Service Coordinators and Account Executives at SarahCare to address client-specific issues and ensure a seamless process for care delivery.

◦ Provide regular updates on the status of authorizations and eligibility cases.

5. Compliance and Documentation:

◦ Ensure all actions and communications are documented in accordance with SarahCare policies and regulatory requirements.

◦ Monitor changes in state and MCO policies to maintain compliance.

6. Problem Resolution:

◦ Address urgent authorization or eligibility issues and work proactively to prevent service interruptions.

◦ Develop and implement best practices to streamline the authorization process.

Qualifications and Requirements:

1. Education and Experience:

◦ High school diploma or GED required; Bachelor’s degree in healthcare administration, social work, or a related field preferred.

◦ Minimum of 2 years of experience in healthcare authorizations, eligibility, or case management, preferably within home care or long-term care.

◦ Previous working experience with HHAeXchange is preferred.

2. Skills and Abilities:

◦ Strong research and investigative skills to identify and resolve issues effectively.

◦ Excellent verbal and written communication skills, with the ability to interact professionally with MCOs, OLTL, and CAOs.

◦ Detail-oriented with strong organizational and time-management skills.

◦ Ability to handle multiple priorities and meet deadlines in a fast-paced environment.

3. Technical Proficiency:

◦ Proficient in Microsoft Office Suite (Word, Excel, Outlook) and experience with healthcare management software.

◦ Familiarity with state-specific systems for eligibility and authorization (e.g., PROMISE PA, NaviNet).

4. Knowledge:

◦ Understanding of Medicaid, managed care processes, and home care services.

◦ Knowledge of Pennsylvania’s OLTL and CAO regulations is a plus.

5. Other Requirements:

◦ Ability to work independently and collaboratively as part of a team.

◦ Strong problem-solving skills and a proactive approach to challenges.

◦ Commitment to maintaining confidentiality and compliance with all legal and regulatory standards.