Payor Specialist – Medical Device, Third-Party Payors

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

📋 Description

• Verify and reverify insurance coverage, eligibility, benefits, procedure coverage, payor requirements, and patient responsibilities.

• Accurately and promptly update eligibility information.

• Submit and monitor authorization requests until final payor determination is achieved.

• Submit and track Letters of Agreement and Single Case Agreement requests through negotiation, execution, or final resolution.

• Obtain, record, and communicate payor determinations, network exceptions, and payment-related decisions.

• Monitor compliance with payor information requests and relay these requests to the appropriate teams.

• Document and convey authorization and LOA/SCA outcomes, subsequent steps, and payor requirements.

• Address out-of-network challenges and take measures to enhance in-network patient benefits.

• Provide insights on payor guidelines, issues, and decisions.

• Follow up on outstanding payor correspondence to promote priority review and expedite responses.

• Interpret payor documentation and translate it for the Case Management Team, customers, and patients.

• Expedite or escalate authorization and LOA/SCA reviews to align with treatment scheduling needs.

• Coordinate daily activities with the Case Management Team and collaborate across departments between management and programs.

• Perform additional duties as assigned.

⛳️ Requirements

• Strong organizational abilities, attention to detail, and effective task management while adapting to shifting priorities.

• Capacity to maintain composure and objectivity in emotional or high-pressure situations.

• Quick learner with the ability to apply innovative techniques, tools, and technology.

• High level of self-accountability regarding adherence to policies, procedures, and work expectations.

• Ability to support multiple products and/or programs across various treatment specialties.

• Capability to independently manage tasks and follow-up responsibilities.

• Understanding of insurance contracts and reimbursement methodologies.

• Proficiency in navigating payment negotiations within specified rate limits.

• Strong knowledge of complex insurance frameworks, including dual coverage, unique insurance plans, purchase orders, and tiered benefits.

• Familiarity with medical terminology.

• Expertise in third-party payor, Medicare/Medicaid guidelines.

• Computer and database management skills for proprietary electronic systems.

• Strong interpersonal and communication skills for collaboration with physicians, hospital leaders, nursing staff, patients, and their families.

• High school diploma with a minimum of five years of healthcare experience OR an Associate's Degree in a healthcare-related field with three to four years of experience.

• Experience with payers and Clinical Guidelines or Medical Policy is preferred.

🏝️ Benefits

• Comprehensive medical, dental, and vision plans.

• Life insurance and disability coverage.

• Tax-advantaged savings accounts.

• Employee Assistance Program.

• Home office benefits.

• Employee Ownership Program.

• Paid time off.

• Paid holidays.

• Bereavement leave.

• 401(k) retirement plan with employer matching.

• Performance-based bonus opportunities.