Prior Authorization & Appeals Specialist id-12349
About the position
Optime Care seeks a Prior Authorization and Appeals Specialist for our Earth City, MO location. We are looking for someone who is passionate about helping people 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. This position will be required to be in the office for the first 120 days for training purposes. After that, it can be a hybrid role, with at least 3 days in-office required depending on business needs.
Responsibilities
- Ensure prior authorizations and appeals cases follow current CMS guidelines and timeliness criteria, which includes communicating directly with providers and insurance companies
- Prepare case files for Independent Review Entities or other levels of the Appeals process
- Document all activities of the Prior Authorizations and Appeals process
- Compose technical denial arguments for reconsideration
- 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
- Assist with internal and external audit processes
- Proactively identifies areas of improvement for self and the department
- Work with assigned clients to assess trends around payer responses
- Participate in the development and completion of individual and departmental initiatives
- Other duties as needed or assigned.
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Requirements
- High school diploma, or equivalent, 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, i.e., 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 an appeal
- 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.
