Prior Authorization Specialist

The Role

The Prior Authorization Specialist is primarily responsible for facilitating pre-service authorization and appeal submissions to insurance companies and external review organizations to obtain coverage for the ReActiv8 Neurostimulation System. This position reports into the Patient Access Program Manager.

Position Responsibilities:

• Handle receipt and data entry of incoming prior authorization requests, including patient consent forms and patient medical records, promptly.
• Review and ensure all necessary documentation are provided to file a prior authorization, a pre-service appeal, or an external review request, when necessary.
• Gather required/additional supporting documentation and information, including state protocols, physician or hospital medical records, state or federal statutes, patient, or physician letters of medical necessity, etc.
• Complete eligibility and verification of patient benefits and coverage for ReActiv8, manually and/or electronically.
• Submit requests to insurance companies for prior authorizations and internal pre-service appeals with collected clinical materials, letters, and reference materials for ReActiv8.
• Submit requests to independent review organizations for external review appeals with collected clinical materials, letters, and reference materials for ReActiv8.
• Follow through with payer correspondence and requests for more information related to each authorization and appeal submission.
• Conduct informative and educational interactions with utilization review and management departments at insurance companies and independent review organizations.
• Communicate with physician offices, theirstaff/clinical contacts, and patients on the progress of their prior authorization or internal appeal requests.
• Provide hard-copy authorization documents to physicians, respective facilities, and patients to support scheduling implantation for ReActiv8.
• Understand and track adverse denial trends and continue to keep up to date on payer policies, regulations, and regional requirements.
• Deliver exceptional customer service to our customers, including physician offices, their clinical staff, patients, and field sales personnel.
• Manage multiple priorities and deadlines successfully, while handling stressful situations accordingly.
• Accept risk and uncertainty.
• Ensure compliance with company policies, specifically patient confidentiality (HIPAA) in all Mainstay Medical practices.
• Perform other duties, as required.

Qualifications:

• Bachelor’s Degree (health economics, life sciences, public health), RN/BSN preferred.
• Experience working for a medical device company or with medical devices, specifically/preferably companies or devices experiencing challing coverage environments.
• Experience submitting and managing prior authorizations, internal provider-based and/or member-based appeals, and external reviews with independent review organizations.
• Nationwide knowledge of health insurance industry practices and functions.
• Experience and knowledge with Medicare, Medicare Advantage, Medicaid, Tricare, Workers Compensation, Federal Employee Plans, and Commercial Insurance.
• Understands and can speak to ICD-10 codes, CPT codes, and HCPCS codes.
• Superior oral and written communication skills.
• Demonstrates excellent organization skills with attention to detail.
• Proficient in Microsoft Office, including Microsoft Word, Outlook, Excel, and PowerPoint.
• Experience working with platforms such as Salesforce, Availity, eFax systems, and other basic database management programs.
• Problem solver and capable to find solutions to challenges or process impediments.
• Maintains a caring, empathetic, and patient-centric approach in all interactions.

The salary range for this position is $69,543 to 90,000/year; however, base pay offered will take into account a range of factors, including job-related knowledge, skills, and experience. The total compensation package includes a range of medical, dental, vision, financial, and other benefits, as well as equity.

Mainstay Medical is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to gender, race, color, religious creed, national origin, age, sexual orientation, gender identity, physical or mental disability, and/or protected veteran status. Mainstay Medical participates in E-Verify.