SDoH Specialist

All Care Health Headquarters, Grants Pass, OR, US

30+ days ago Requisition

Salary Range: $25.00 To $28.00 Hourly

We Are Seeking Qualified Candidates to Join Our Team!

All Care Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.

This position is responsible for the timely processing of Health-Related Services (HRS) invoicing, flexible service requests and prior authorization requests specific to Social Determinants of Health (SDoH) and Health Related Social Needs (HRSN). As a Subject Matter Expert (SME) in SDoH, the role collaborates with internal CCO teams and external community partners to remove barriers within the healthcare system.

• Provides subject matter expertise on prior‑authorization requirements and processes for SDoH / HRSN and HRS flexible services.
• Process service determinations for SDoH / HRSN and HRS requests as required by department policy and procedures.
• Maintain accurate inventory records using department spreadsheets for flex items and HRSN climate devices.
• Coordinates the dispensing of approved items kept in-house, ensuring proper documentation to support member distribution to the Population Health team.
• Submits monthly claims for SDoH/HRSN benefits for Housing (Rent/Utilities/Storage), Climate, Administrative Fees, Home Modification/Remodification and Outreach and Engagement.

• Ensures service determination requests are completed within the required government time frames by reviewing daily EZCap HRS Request 8111 report.
• Research and apply relevant federal and/or state criteria and/or health plan policies for service determinations.
• Maintain up‑to‑date knowledge of relevant Oregon Administrative Rules (OARs)
• Verifies member eligibility and benefit coverage for all insurance products.
• Perform invoice reconciliation for HRSN Outreach and Engagement services, matching provider invoices to system entries for accuracy and notifying Population Health Leadership for care plan development.
• Order HRS and HRSN climate devices in accordance with OHA specifications and department policy.
• Oversees inventory levels for hygiene/camping kits, balancing stock levels to ensure availability while minimizing cost.
• Assemble hygiene and camping kits as designated by leadership to ensure appropriate stock levels and availability.
• Composes and delivers service determination notifications (extensions, approvals, adverse decisions) and informs individuals of grievance/appeal rights according to department policy and procedure.
• Reviews HRSN data reports weekly to ensure accuracy of authorizations.
• Processes all HRS/Flex requests according to department policy and procedure.
• Records approved HRS and HRSN items in department spreadsheets as required per department policy and procedure.
• Receive, reconcile, and check eligibility for all billing invoices and spreadsheets from HRS partner organizations and send to SDOH Benefit Manager and Director of BM & PS for final approval and finance processing.
• Maintains financial records in department spreadsheets for HRS‑related expenses, ensuring cumulative expenditures remain within the designated annual capitation threshold.
• Assists in the development, preparation, and submission of regular deliverables surrounding rules and data related to HRSN/ and/or HRS flexible services.
• Responds to all HRS/flex emails and HRSN emails as delegated by Lead SDoH Specialist.
• Monitors and reviews daily public website inquiries via report and Unite Us and communicates with Population Health leadership to ensure timely member follow‑up.
• Stays current on federal/state regulations and health plan policies to inform service determinations.
• Identifies workflow inefficiencies and recommends process improvements.
• Maintains courteous and professional relationships with providers and stakeholders.
• Communicates concerns to leadership, seeking guidance and resolution support.
• Demonstrates adaptability, efficiency, and independent…