What are the responsibilities and job description for the Prior Authorization and Appeals Specialist position at Converge HR Solutions?
What they are looking for
Our client seeks a Prior Authorization and Appeals Specialist for our Berwyn, PA location. They are looking for people who are passionate about helping patients get the specialized therapies they need. This critical role manages the process of receiving, researching, and resolving prior authorizations and appeals issues with health insurance companies, including any escalated step of the appeals process following federal regulatory requirements and policies and procedures.
For the first 120 days, this position will be required to be in the office five days a week, Monday through Friday, for training purposes.
The job details
About our client
Our client is a Specialty Pharmacy dedicated to providing services to smaller patient communities. We focus on securing insurance coverage, coordinating care, and complying with therapy regimens are only a few examples. Our mission is to minimize the daily impact of living with unique disorders. After just one call, our experts begin to address everything from medication delivery and insurance reimbursement to compliance and education. Every patient receives a proactive service experience tailored to their specific needs.
Our client seeks a Prior Authorization and Appeals Specialist for our Berwyn, PA location. They are looking for people who are passionate about helping patients get the specialized therapies they need. This critical role manages the process of receiving, researching, and resolving prior authorizations and appeals issues with health insurance companies, including any escalated step of the appeals process following federal regulatory requirements and policies and procedures.
For the first 120 days, this position will be required to be in the office five days a week, Monday through Friday, for training purposes.
The job details
- Ensure prior authorizations and appeals cases follow current CMS guidelines and timeliness criteria, including communicating directly with providers and insurance companies.
- Document all activities of the Prior Authorizations and Appeals process.
- Respond to Prior Authorization denials and submit appeals, collecting appropriate clinical support to substantiate the formal response.
- Compose technical denial arguments for reconsideration, both written and verbal.
- Overcome objections that prevent payment of claims and gain commitment for payment through a concise and effective appeal argument.
- Identify problem payors, processes, and trends and escalate where appropriate.
- Utilize documentation standards that support a strong historical record of actions taken.
- Write and complete final editing of letters of determination sent out for appeals.
- Produce and manage inbound and outbound correspondence in a manner that meets required timeframes.
- Works collaboratively and cross-functionally with other departments to facilitate appropriate resolutions.
- Prepare case files for Independent Review Entities or other levels of the Appeals process.
- Assist with internal and external audit processes.
- Work with assigned clients to assess trends around payer responses.
- Participate in the development and completion of individual and departmental initiatives.
- Perform other related duties as assigned or as necessary; remain flexible and adaptable in work schedules and work assignments as defined by departmental and organizational needs.
- A high school diploma or equivalent is required.
- 2 or more years of experience with medical/pharmacy insurance verification, including benefit investigation.
- Knowledge of prior authorizations and claim appeals is necessary.
- Knowledge of medical terminology is required.
- Current Missouri BOP Pharmacy Technician license or Nurse license in good standing.
- Knowledge of medical/pharmacy insurance benefits language, such as EOBs, deductibles, Out-of-pocket, coinsurance, co-pays, etc.
- Ability to work independently with limited supervision.
- Effectively meet established productivity, schedule adherence, and quality standards.
- Ability to define CMS 1500s, provider numbers, CPT, HCPC’s, ICD9, NCPDP and NDC codes/numbers.
- Relentless attention to detail and the ability to be a creative self-starter and team player.
- Ability to utilize critical thinking skills to identify issues and required actions within appeals.
- Computer literate and proficient with Microsoft Office.
- Ability to participate in and facilitate group meetings.
- Ability to thrive in a fast-paced environment with constantly changing and competing priorities.
- Excellent analytical skills and the ability to provide solutions to complex problems.
- Ability to be highly transparent, ethical, and driven.
- Excellent written and verbal communication skills and interpersonal skills required.
- Willingness to work a flexible schedule to support different time zones across the country.
About our client
Our client is a Specialty Pharmacy dedicated to providing services to smaller patient communities. We focus on securing insurance coverage, coordinating care, and complying with therapy regimens are only a few examples. Our mission is to minimize the daily impact of living with unique disorders. After just one call, our experts begin to address everything from medication delivery and insurance reimbursement to compliance and education. Every patient receives a proactive service experience tailored to their specific needs.
Converge HR Solutions and our clients provide equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
