Pre-Authorization Specialist II

Job Title: Pre-Authorization Specialist II
Job Location: Marlborough, MA
Job Duration: 6 Months (possibility of extension)
Payrate:  $20 - $25/ hr. on w2

Job Summary:

• The Pre-Authorization Specialist II is responsible for performing benefit verification, prior authorization, and appeal functions of the Patient Access Support Program (PASP).
• This position will work closely with PASP team members, internal and external customers, and payers to secure insurance approval for Endobariatric procedures using client devices.

Responsibilities:

• Verify medical insurance benefits and coverage, including the ability to obtain and process payer forms.
• Submit prior authorization/pre-determination requests, and internal and external appeals to health plans to assist the team in achieving identified goals and objectives.
• Apply pressure on health plans that refuse to review based on negative or absent coverage policy for Endobariatric procedures (i.e., Endoscopic Sleeve Gastroplasty, Transoral Outlet Reduction Endoscopy).
• Follow up on prior authorization and appeal requests to health plans to ensure receipt and proper review for medical necessity.
• Monitor and re-engage payer until final determination is made, ensuring each available level of appeal is used and all appeal rights are exhausted.
• Answer incoming calls received through the toll-free PASP call center, providing superior customer service and appropriate call/case handling.
• Utilize proficient knowledge in Microsoft Office and Salesforce to document case statuses, actions, and outcomes in a timely and accurate manner.
• Effectively communicate and build relationships with HCP office and internal stakeholders regarding all inquiries and handling of cases.
• Maintain PASP metrics and standards.
• Process incoming emails by responding and triaging inquiries in an appropriate manner.
• Process incoming faxes to efficiently manage service requests and facilitate communication from customers, patients, and payers as appropriate.
• Report adverse events/product complaints following program Standard Operating Procedures (SOPs).
• Comply with SOPs to maintain data integrity.
• Maintain HIPAA compliance and patient confidentiality.
• Engage and commit to the organization's culture of continuous improvement by actively participating, supporting, and promoting Client's Mission and Values.
• Consistently provide superior quality and service in a high-volume work environment.
• Coordinate with lead regarding complicated cases.
• Other duties as assigned.

Education and Experience:

• High school diploma.
• Associate’s degree
• Medical device experience and/or bariatric experience preferred.
• Experience utilizing software/systems to perform tasks (e.g., Salesforce, EMR, payer portals, Policy Reporter).
• Experience interpreting medical necessity and experimental/investigational denials and drafting appeals.

Minimum 2-years’ relevant experience including:

• Working with various payers including, Medicare, Medicaid, Private/Commercial, and VA.
• Reviewing clinical records and extracting key information to support medical necessity.
• Submitting prior authorization requests for medical procedures.
• Understanding and leveraging payer coverage criteria to ensure positive outcomes.

Skills and Abilities:

• Proficient in Microsoft Office.
• Excellent written and verbal communication skills.
• Ability to work independently with minimal to moderate supervision.