Patient Access Specialist – Differential Waiver

This is a fully remote position, open to applicants in Wisconsin.

📋 Description

• Assess and confirm insurance eligibility, prior authorization, and medication/procedure referrals.

• Gather documentation and engage with third-party payers, healthcare professionals, and clients.

• Verify patient registration and coverage benefits, including deductibles and out-of-pocket costs.

• Investigate covered benefits for requested tests, procedures, and additional services.

• Complete and validate prior authorization for medical services, testing, procedures, surgeries, durable medical equipment (DME), and medications.

• Retrieve diagnosis and CPT codes from medical records or provider offices.

• Reach out to third-party payers regarding prior authorization protocols.

• Work alongside provider offices to clarify documentation and establish medical necessity.

• Follow up with provider offices about Advance Beneficiary Notices (ABNs) or waivers when criteria for medical necessity are not satisfied.

• Review denials of professional services and assist with the appeals process.

• Ensure necessary referrals are established and manage outgoing referrals.

• Inform insurance companies about inpatient services and procedures that require observation periods.

• Document activities in the case management module and guide utilization management, case management, and nursing teams.

• Collaborate with case management, social work, utilization management, and cross-functional teams.

• Aid in data design and management, including generating reports and presentations.

⛳️ Requirements

• High school diploma or equivalent is preferred; post-secondary education is advantageous.

• A minimum of two years of experience in a hospital or clinic environment is required.

• Proficiency in medical terminology is essential.

• Background in insurance is mandatory.

• Competence in office equipment and computer skills is required.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with employer matching contributions.

• Paid time off and holidays.

• Opportunities for professional development and continuing education.

• Supportive work environment and team-oriented culture.