Appeals Specialist

Position Summary

The Patient Access Appeals Specialist is part of the HFX Access team, playing a critical role in securing payer coverage for patients. The role involves working in collaboration with HFX Access, Market Access and Field personnel to provide customer support from prior authorization submission through the final appeals process.

Essential Functions

• Partner with internal partners to secure HFX Access and drive effective pull-through with payers

• Meet metrics and timeliness standards to achieve individual and department performance goals as defined within the department guidelines

• Develop sound and well-supported appeal argument letters of patient appeal based on payer policy

• Thoroughly review medical records and other documentation provided by physicians for completeness and identify missing information necessary for submitting an appeal

• In conjunction with GAMA and HFX Access team members, stay current on payer coverage policies and patient requirements for HFX therapy as well as stay current on the impact of health care reform to patient’s access to HFX therapy

• Leverage knowledge of applicable medical policies, Nevro clinical publications, and other resources that can be used to strengthen appeals

• Respond to all patient, physician, office staff, and field communications in a timely manner

• Provide timely updates about the case status to the field representative and customer contact

• Provide complete review of payer communication for assigned patient case (i.e., approval and denial letters) and share findings with local sales team and customer contact

• Maintain oversight to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures

• Report all complaints regarding products to the appropriate Company personnel within the required time frames

• Ensure compliance with company Compliance policy, in particular patient confidentiality (HIPAA) in all team practices

• Adhere to the letter and spirit of the company Code of Conduct, the AdvaMed Code, MedTech Code, and all other company policies

• Ensure compliance with applicable governmental laws, rules, and regulations, both in the United States and internationally, by completing introductory and annual training and maintaining knowledge of compliance as it applies to your role

• Represent the company in a professional manner and uphold the highest standards of ethical business practices and socially responsible conduct in all interactions with other employees, customers, suppliers, and other third parties

Qualifications

• Bachelor’s degree in related field

• 2+ years of applicable experience in reimbursement support relating to appeals and prior authorizations from a payer, provider or medical device/pharmaceutical industry required

• Demonstrate the ability to draft professional and effective appeal letters

• Prior experience and knowledge of health insurance business, industry terminology, and regulatory guidelines

• Prior patient appeals experience is preferred

• Prior experience with Medicare, Medicaid, TRICARE, Workers Compensation and Commercial Insurance is preferred

Physical Demands

• Required to sit; climb or balance; and stoop, kneel, crouch or crawl

• Required to regularly lift and/or move up to 10 pounds, and occasionally lift and/or move up to 25 pounds

• Required to possess specific vison abilities, including: close vision, distance vision, color vision, peripheral vision, depth perception and capacity to adjust focus