Patient Access Specialist – Medical Necessity Investigation

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

📋 Description

• The Patient Access Specialist is a mid-level position within the Patient Access team, tasked with assisting our client's reimbursement needs to enhance patient access to their technologies and procedures.

• This role will engage with various key economic stakeholders, including representatives from client companies and their customers, such as physicians, billing and coding personnel, hospitals, and ambulatory surgical centers.

• The individual will act as a subject matter expert in patient access services, covering areas such as benefits verification, prior authorization, pre-service appeals, and post-service claims appeals.

• A fundamental responsibility of this role includes executing thorough medical necessity investigations by carefully reviewing patient clinical documentation and cross-referencing it with payer-specific medical policies, coverage guidelines, and authorization criteria to assess eligibility and support coverage approval.

• Strong analytical and critical thinking skills are required to interpret clinical information, identify documentation gaps, and formulate strategic recommendations to enhance reimbursement outcomes.

• This position will also entail navigating intricate payer requirements, investigating policy nuances across both commercial and government payers, and collaborating with providers and internal stakeholders to gather and verify the clinical information necessary for authorization and appeal submissions.

• Participation in weekly program calls as necessary.

• Conduct 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 of Patient Access.

• Manage a case load for an assigned program.

• Input and review new patient cases in the system database.

• Act as the primary point of contact for providers and patients seeking assistance with insurance coverage.

• Regularly communicate with physicians' offices and their staff.

• Maintain accurate and current records within the Salesforce platform to ensure precise reporting to clients.

• Complete the entire patient access process as specified by the program SOP, including, but not limited to, analyzing and interpreting patient clinical data, clinical notes, and files to confirm that medical necessity criteria are met as per each payer policy.

• Review multiple insurance policies to establish medical necessity criteria that support medical device/procedure(s).

• Conduct case-related research (e.g., payer coverage policies, self-funded plans, state and federal regulations).

⛳️ Requirements

• A college degree is preferred, but applicable work experience may be considered in lieu.

• A minimum of 4 to 5 years of experience in a healthcare environment, ideally in authorization or billing.

• Comprehensive knowledge of insurance processes, medical terminology, and healthcare regulations.

• Preferred experience in supporting mental health treatment programs, particularly those related to Major Depressive Disorder (MDD).

• Familiarity with Medicaid, Medicare, and commercial payer requirements, including prior authorization and appeals processes.

• Strong problem-solving abilities.

• Capability to remain patient, empathetic, and composed during lengthy, intensive interactions with individuals facing mental health challenges.

• Excellent analytical and problem-solving skills.

• Outstanding communication and interpersonal abilities.

🏝️ Benefits

• Uphold strong professionalism, ethics, and compliance with all applicable laws and policies.

• Ensure adherence to all regulatory and company policies.