Work mode: Remote in Country

Onsite Location(s):Arden Hills, MN, US, 55112

About the role:

• Follow up on prior authorization requests to health plans to ensure receipt and proper review for medical necessity.
• Apply pressure on health plans that refuse to review based on negative or absent coverage policy for Intracept.
• Accurately identify payer denial reasons and develop an action plan for appeal.
• 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.
• Participate in administrative law judge hearings via phone, presenting on behalf of the Medicare Advantage patient.
• Submit prior authorization requests to health plan as needed to assist the team achieving identified goals and objectives.
• Draft all case related communication to physicians, patients and payers in a clear and concise manner.
• Document all case activity and correspondence for cases in a timely and accurate 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.
• 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.).
• Act as a resource for fellow team members and new employees.
• Prioritize tasks according to urgency:
  • Expected Total case volume 140-160
  
  

• 2+ years’ experience in a pain management/spine prior authorization role. Experience must include:
  • Reviewing clinical records and extracting key information to support medical necessity
  • Submitting prior authorization requests for medical procedures
  • Interpreting procedure denials and drafting appeals
  • Understanding and leveraging payer coverage criteria to ensure positive outcomes
• 2+ years utilizing software systems to perform tasks
• Travel < 5%
• 40-hour work week
• Ability to sit/stand at a workstation 8 hours per day
• High school diploma

• Neuromodulation/Basivertebral nerve ablation experience
• Ability to communicate clearly and assertively with payers
• Strong written and verbal communication skills
• Software experience, i.e. EMR, payer portals, Microsoft Office, Salesforce