PRIA Healthcare

Compensation

Full Description

Position Overview: The Patient Access Specialist - Director is a mid-level role, within the Patient Access team, and is responsible for supporting our client’s reimbursement needs to facilitate patient access to their technologies and procedures. This position will support a variety of key economic stakeholders including client company representatives and their customers including physicians, billing and coding personnel, hospitals, and ambulatory surgical centers. This position will be accountable to serve as an expert resource in patient access services including, benefits verification, prior authorization, pre-service appeals and post service claims appeals. Key Responsibilities: • Participation on weekly program calls as needed. • Train and mentor new patient access specialists. • Audit a select number of cases per program as directed by the Director/Manager, Patient Access. • Manage a case load for an assigned program. • Data entry and review of new patient cases into system database. • Serve as a primary point of contact for providers and patients seeking insurance coverage assistance. • Communicate with physician’s office and their staff regularly. • Maintain accurate and up-to-date records within the salesforce platform to ensure accurate reporting to clients. • Complete full patient access process as outlined by program SOP including but not limited to: •  Analyze and interpret patient clinical data, clinical notes and files to determine medical necessity criteria is met specific to each payer policy •  Review multiple insurance policies to define medical necessity criteria to support medical device/procedure(s) •  Conduct case-related research (e.g., payer coverage policies, self-funded plans, state and federal regulations). •  Benefits verification •  Prior Authoriation/ Pre- service review submissions, pre and post service appeal submissions •  Ensure all documents developed to support an appeal are accurate, consistent, up to date, and in compliance with applicable Standard Operating Procedures, guidelines, and regulations. •  Maintain strong professionalism, ethics, and compliance with all applicable laws and policies •  Ensure compliance with all regulatory and company policies. KPI's: Established based on the program complexity and align with program success: • Once KPIs are established they are measured daily, weekly and monthly Qualifications: • College degree preferred but will substitute for applicable work experience • Minimum of 4-5 years experience in a healthcare setting, preferably in authorization or billing. • In-depth knowledge of insurance processes, medical terminology, and healthcare regulations. • Preferred experience with supporting mental health treatment programs, specifically those related to Major Depressive Disorder (MDD) • Knowledge of Medicaid, Medicare, and commercial payer requirements, including prior authorization and appeals processes. • Strong problem-solving skills. • Ability to remain patient, empathetic, and composed throughout long, time-intensive interactions with individuals experiencing mental health challenges • Strong analytical, and problem-solving skills. • Excellent communication and interpersonal skills.