State Operations Coverage Specialist

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

Network & Coverage Verification (45%)

• 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.

Required Qualifications

Education

• High school diploma or GED, and completion of formal training or coursework in healthcare administration, patient services, or a similar field.

Minimum Experience

• 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.

Our benefits: supporting your total wellbeing

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.

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.

Originally posted on Himalayas