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Mainstay Medical · 3 weeks ago

Prior Authorization Specialist

San Diego, CA

Full-time

Onsite

Entry, Mid Level

$74K/yr - $84K/yr

2+ years exp

Mainstay Medical is a medical device company focused on marketing an innovative implantable neurostimulation system, ReActiv8®, for people with disabling chronic mechanical Low Back Pain. The Prior Authorization Specialist is primarily responsible for facilitating pre-service authorization and appeal submissions to insurance companies and external review organizations to obtain coverage for the ReActiv8 Neurostimulation System.

BiotechnologyEmergency MedicineHealth CareMedicalMedical Device

Responsibilities

Handle receipt and data entry of incoming prior authorization requests, including patient consent forms and patient medical records, promptly

Review and ensure all necessary documentation are provided to file a prior authorization, a pre-service appeal, or an external review, when necessary

Gather required/additional supporting documentation and information, including state protocols, physician or hospital medical records, state or federal statutes, patient, or physician letters of medical necessity, etc

Complete eligibility and verification of patient benefits and coverage for ReActiv8, manually and/or electronically

Submit requests to insurance companies for prior authorizations and internal pre-service appeals with collected clinical materials, letters, and reference materials for ReActiv8

Submit requests to independent review organizations for external review appeals with collected clinical materials, letters, and reference materials for ReActiv8

Follow through with payer correspondence and requests for more information related to each authorization and appeal submission

Conduct informative and educational interactions with utilization review and management departments at insurance companies and independent review organizations

Communicate with physician offices and staff/clinical contacts on the progress of their prior authorization or internal appeal requests

Provide hard-copy authorization documents to physicians and respective facilities to support scheduling implantation for ReActiv8

Understand and track adverse denial trends and continue to keep up to date on payer policies, regulations, and regional requirements

Deliver exceptional customer service to our customers, including physician offices, their clinical staff, patients, and field sales personnel

Manage multiple priorities and deadlines successfully, while handling stressful situations accordingly

Accept risk and uncertainty

Ensure compliance with company policies, specifically patient confidentiality (HIPAA) in all Mainstay Medical practices

Perform other duties, as required

Qualification

Prior authorization experienceHealth insuranceCommunication skillsMicrosoft Office proficiencyMedicare/MedicaidEmpathetic approachOrganizational skillsProblem-solving skills