Infusions and Specialty Pharmacy Reviewer

📋 Description

• Evaluate the outputs of the model to enhance criteria determinations.

• Identify incorrect determinations, including false positives, false negatives, and ambiguous logic, providing structured feedback.

• Compare documentation with Medicare, Medicaid, and commercial payer coverage policies.

• Examine source materials (insurance policies, LCDs, etc.) to assist in validating qualification logic.

• Collaborate closely with internal teams to refine prompting logic and elevate documentation review standards.

• Keep thorough documentation of findings and contribute to ongoing process improvements.

⛳️ Requirements

• You possess hands-on experience in infusions/SP roles such as intake, documentation review, case management, and clinical review.

• You are adept at determining when documentation meets or does not meet payer requirements.

• You are at ease reviewing insurance coverage policies and applying them to actual cases.

• You are highly organized, detail-oriented, and confident in making policy-based decisions.

• You excel in working independently and appreciate open communication within a remote team environment.

• A minimum of 4 years of experience in infusions/SP, preferably in intake, documentation review, case management, and clinical review.

• You are tech-savvy and comfortable utilizing AI tools in your daily tasks to enhance accuracy and efficiency.

• Familiarity with Medicare, Medicaid, and commercial payer guidelines for infusions/SP is preferred.

• Understanding of HCPCS codes, NDCs, and common infusion/SP drug categories across various therapeutic areas (e.g., neurology, inflammation, and immunology) is advantageous.

• Experience with audits, prior authorizations, and appeals is a significant plus.

• Familiarity with decision logic or rules-based platforms is beneficial but not mandatory.

🏝️ Benefits

• Unlimited PTO.

• Full-Remote Flexibility.

• 100% paid employee health benefit options.

• Employer-funded 401(k) match.

• Competitive parental leave.