The Prior Authorization Specialist is responsible for managing the patient authorization and appeal process. Working closely with Relievant team members and external customers (Physicians and Patients) to identify and overcome obstacles in the patient access program and reimbursement environment.

Essential Functions:

• Prior Authorization submission as needed to assist the team achieving identified goals and objectives.
• Review and understand payer denials, determining appropriate next step according to payer appeal guidelines and internal Relievant process.
• Monitor and re-engage payer until final determination is made – ensuring each level of appeal is utilized and all appeal rights are exhausted.
• Participate in Administrative Law Judge hearings as a final attempt to obtain coverage for Medicare Advantage cases.
• Complete all communication to physician, patients, and payers in a clear and accurate manner.
• Document all account activity and correspondence for cases in a timely/accurate manner so any team member can see exactly what is happening with each case and act on it as needed.
• Confirm accuracy of authorization details, ensure 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.
• Clearly communicate with Internal and External customers regarding patient access to Intracept Procedure, including but not limited to (case status, needed information, TM involvement, reporting etc.).
• Prioritize tasks according to urgency:
• Expected Total case volume: 150-175
• Expected completed tasks per day 40-50

Experience:

• Minimum 2-years authorizing medical procedures/surgeries with commercial payers. (pain management/spine preferred)
• Minimum 1-year claim appeal experience (preferred).

Skills/Aptitudes:

• Demonstrated ability to navigate the prior authorization and appeals process with commercial and government payers.
• Ability to follow process and protocol and communicate when/if changes are needed.
• Ability to work within multiple software systems.
• Ability to remain self-motivated and productive in a remote work environment.
• Ability to adapt as the needs of the business change or evolve.
• Excellent verbal and written communication skills.
• Excellent interpersonal skills.

Work Requirements:

• Secure home office space with ability to protect HIPAA sensitive materials.
• Home access to high-speed internet service.
• Must be willing to travel as needed (<5%).

Education:

• High School Diploma or equivalent.

Location:

Anywhere in the United States. This position is 100% remote