Pre-Authorization Specialist II

Job Description: REMOTE POSITION - US BASED
Ideal candidate:
Has worked with Salesforce tool/environment
Understands complex pre-auth - non covered services
someone who is used to calling insurance companies/appeals, etc.
Pre-authorization experience
***Medical device/pharma/oncology background

About the role:
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 *** devices.

Your responsibilities will include:
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

Required qualifications:
High school diploma
Minimum 2-years relevant experience including:
o Working with various payers including, Medicare, Medicaid, Private/Commercial, and VA
o Reviewing clinical records and extracting key
information to support medical necessity
o Submitting prior authorization requests for medical procedures
o Understanding and leveraging payer coverage criteria to
ensure positive outcomes
Proficient in Microsoft Office
Excellent written and verbal communication skills
Ability to work independently with minimal to moderate supervision

Preferred qualifications:
Associates 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