RCM Benefits Verification – Prior Authorization Specialist

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

📋 Description

• Perform comprehensive benefit verifications via phone and online portals. Once a patient is deemed clinically suitable, you will manage the VOB from initiation to completion.

• Identify details overlooked by automated checks — including medical versus pharmacy routing, code-level coverage, precise deductible/OOP status, coinsurance, coordination of benefits, and prior authorization prerequisites.

• Convert VOB findings into a straightforward, actionable summary for the practice. Use clear language to ensure the practice can act on your findings without needing further clarification.

• Oversee the entire PA lifecycle for Spravato, TMS, and other therapies: from initial submission to approval, including proactive re-authorization to prevent any interruptions in care.

• Choose the appropriate submission channel based on the payer and treatment type (CoverMyMeds, Availity, payer-specific portals, or fax/phone when necessary).

• Actively monitor the status of submissions. Follow up before issues arise. In the event of a denial, ascertain the reason and coordinate appeals or peer-to-peer requests with the practice.

• Comprehend each payer's requirements and ensure clinical documentation validates medical necessity prior to submission.

• When a VOB or PA response appears inconsistent, investigate thoroughly — do not merely document and move on.

• Engage payers with targeted inquiries. Cross-reference portal data with phone information to determine if the issue stems from a data error, policy misapplication, or an actual coverage limitation.

• Escalate issues with context: when you bring a concern to the team, ensure you have already conducted the necessary groundwork.

• Craft clear, concise, and professional communications to practices. Every benefit summary, PA update, and denial notice should be actionable by a provider without requiring follow-up calls.

• Maintain composure and organization when facing confusing or frustrating payer outcomes. Your thoroughness and communication quality will reassure practices that they are in capable hands.

• Manage your own workload efficiently. Flag authorizations nearing expiration promptly. Address blockers specifically and without delay — do not let problems persist.

• Quickly and independently learn new platforms. All internal tools are proprietary; you will not have prior experience with them, and this is anticipated. What matters is your confidence and resourcefulness in mastering them.

⛳️ Requirements

• A minimum of 2 years of hands-on experience in benefit verification and prior authorization (not limited to claims or cash posting).

• Strong understanding of VOB terminology and processes: deductibles, coinsurance, OOP maximums, medical versus pharmacy routing, PBMs, and coordination of benefits.

• Comprehensive PA lifecycle experience: from submission and status monitoring to denial management and appeals.

• Familiarity with major payer portals (such as Availity, Navinet, Optum, or payer-specific) and pharmacy PA platforms (like CoverMyMeds or equivalent).

• Exceptional written English skills — capable of drafting provider-facing messages that require no edits.

• Proven ability to independently learn new technologies.

• Must be US-based and eligible for remote work.

🏝️ Benefits

• Healthcare

• Dental

• Vision

• Generous family leave

• FSA/DCFSA

• Mental health benefits

• 401(k) plan

• Flexible paid time off