Patient Access Specialist - Medical Necessity Investigation

Key Responsibilities

• Participation on weekly program calls as needed
• Perform detailed medical necessity investigations by cross-referencing patient clinical documentation, physician notes, and supporting records against payer-specific coverage policies and authorization criteria to determine eligibility for medical device and procedural approval.
• Train and mentor new patient access specialists.
• Audit a select number of cases per program as directed by the Director/Manager, Patient Access
• Manage a case load for an assigned program
• Data entry and review of new patient cases into system database
• Serve as a primary point 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 within the salesforce platform to ensure accurate reporting to clients.
• Complete full patient access 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 criteria is met specific to each payer policy
• Review multiple insurance policies to define medical necessity criteria to support medical device/procedure(s)
• Conduct case-related research (e.g., payer coverage policies, self-funded plans, state and federal regulations).
• Benefits verification
• Prior Authorization/ Pre- service review submissions, pre and post service appeal submissions
• Ensure all documents developed to support an appeal are accurate, consistent, up to date, and in compliance with applicable Standard Operating Procedures, guidelines, and regulations.
• Maintain strong professionalism, ethics, and compliance with all applicable laws and policies
• Ensure compliance with all regulatory and company policies.

Qualifications

• College degree preferred but will substitute for applicable work experience
• Minimum of 4-5 years experience in a healthcare setting, preferably in authorization or billing
• In-depth knowledge of insurance processes, medical terminology, and healthcare regulations
• Preferred experience with supporting mental health treatment programs, specifically those related to Major Depressive Disorder (MDD)
• Knowledge of Medicaid, Medicare, and commercial 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
• Excellent communication and interpersonal skills