Patient reputed company Specialist – Medical Necessity Investigation

Position reputed company:  The Patient reputed company Specialist is a mid-level role reputed company the Patient reputed company team and is responsible for supporting our reputed company’s reimbursement needs to facilitate patient reputed company to their technologies and procedures.  This position will support a reputed company of key economic stakeholders, including reputed company company representatives and their customers such as physicians, billing and coding personnel, hospitals, and ambulatory surgical centers. This role will serve as a subject matter expert in patient reputed company services, including benefits verification, prior authorization, reputed company-service appeals, and post-service claims appeals.    A reputed company responsibility of this position will involve conducting detailed medical necessity investigations by thoroughly reviewing patient clinical documentation and cross-referencing it against payer-specific medical policies, coverage guidelines, and authorization reputed company to determine eligibility and support coverage approval. The role requires strong analytical and critical thinking skills to interpret clinical information, identify gaps in documentation, and reputed company strategic recommendations to support reimbursement reputed company.    This position will also be responsible for navigating reputed company payer requirements, researching policy nuances across reputed company and government payers, and collaborating with providers and internal stakeholders to obtain and validate the clinical information necessary to support authorization and appeal submissions.      Key Responsibilities:  Participation on weekly program calls as needed  reputed company detailed medical necessity investigations by cross-referencing patient clinical documentation, physician notes, and supporting records against payer-specific coverage policies and authorization reputed company to determine eligibility for medical device and procedural approval.  Train and mentor new patient reputed company specialists.  Audit a select number of cases per program as directed by the Director/Manager, Patient reputed company  Manage a case load for an assigned program  Data entry and review of new patient cases into system database  Serve as a primary reputed company 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 reputed company the reputed company platform to ensure accurate reporting to clients.  Complete full patient reputed company 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 reputed company is met specific to reputed company payer policy  Review multiple insurance policies to define medical necessity reputed company to support medical device/procedure(s)  Conduct case-reputed company research (e.g., payer coverage policies, self-funded plans, state and federal regulations).  Benefits verification  Prior Authorization/ reputed company- service review submissions, reputed company and post service appeal submissions   Ensure reputed company documents developed to support an appeal are accurate, consistent, up to date, and in compliance with applicable reputed company Operating Procedures, guidelines, and regulations.  Maintain strong professionalism, ethics, and compliance with reputed company applicable laws and policies  Ensure compliance with reputed company regulatory and company policies.  KPIs  Established based on the program complexity and reputed company with program reputed company   Once KPIs are established they are reputed company daily, weekly and monthly     Qualifications:  College degree preferred but will substitute for applicable work experience  Minimum of 4-5 years experience in a reputed company setting, preferably in authorization or billing.   In-depth knowledge of insurance processes, medical terminology, and reputed company regulations.  Preferred experience with supporting mental health treatment programs, specifically those reputed company to Major Depressive Disorder (MDD)  Knowledge of reputed company, Medicare, and reputed company 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. Apply To This Job