Patient Access Case Manager

This role involves close collaboration with team members and external customers, including physicians and patients, to navigate obstacles in the patient access program and reimbursement environment.

Responsibilities

•  Submit and follow up on prior authorization requests to health plans to ensure receipt and proper review for medical necessity.
• Persuasively engage health plans that are unwilling to review prior-authorization(s) based upon negative or absent coverage policy for MISHA.
• Draft letters for appeal, external review, and administrative law judge hearings.
• Monitor and re-engage payer until final determination is made, ensuring each available level of appeal is used and all appeal rights are exhausted.
• Document all case-related communication and activity to physicians, patients, and payers in a clear and concise manner to provide chronological details of case progress.
• Confirm accuracy of authorization approval details, ensuring all codes are captured and authorization is within approved timeframes prior to surgery.
• Manage and monitor payer trends as it relates to approvals/denials and communicate trends to the team leadership.
• Clearly communicate with internal and external customers regarding patient access to MISHA, including but not limited to case status, needed information, TM involvement, reporting, etc.
• Act as a resource for fellow team members and new employees.
• Prioritize tasks according to urgency.
• Maintain a case volume up to 150 cases at a time.

JOB REQUIREMENTS:

Education and Training

• 3+ years’ experience in prior authorization and appeals management
• Experience submitting prior authorization requests for medical procedures and interpreting procedure denials to draft appeals
• Understanding and leveraging payer coverage criteria to ensure positive outcomes
• 3+ years utilizing software systems to perform tasks
• High school diploma

• >10% Travel