Prior Authorization & Appeals Specialist
Optime Care
- Earth City, MO
- Permanent
- Full-time
- Ensure prior authorizations and appeals cases follow current CMS guidelines and timeliness criteria which includes communicating directly with providers and insurance companies.
- Prepare case files for Independent Review Entities or other levels of the Appeals process.
- Document all activities of the Prior Authorizations and Appeals process.
- Compose technical denial arguments for reconsideration.
- Overcome objections that prevent payment of claims and gain commitment for payment through concise and effective appeal argument.
- Identify problem payors, processes, and trends and escalating where appropriate.
- Utilize documentation standards that support a strong historical record of actions taken
- Write and complete final editing of letters of determination sent out for appeals.
- Produce and manage inbound and outbound correspondence in a manner that meets required timeframes.
- Prepare case files for Independent Review Entities or other levels of the Appeals process.
- Assist with internal and external audit processes.
- Proactively identifies areas of improvement for self and the department.
- Work with assigned clients to assess trends around payer responses.
- Participate in the development and completion of individual and departmental initiatives.
- Other duties as needed or assigned.
- High school diploma, or equivalent, required.
- 2 or more years of experience with medical/pharmacy insurance verification including benefit investigation.
- Current Missouri BOP Pharmacy Technician license, or Nurse license in good standing.
- Knowledge of prior authorizations and claim appeals.
- Medical terminology required.
- Knowledge of medical/pharmacy insurance benefit language; ie. EOBs, deductibles, Out of pocket, coinsurance, co-pays, etc.
- Ability to work independently, with limited supervision.
- Effectively meet established productivity, schedule adherence, and quality standards
- Ability to define CMS 1500s, provider numbers, CPT, HCPC’s, ICD9, NCPDP and NDC codes/numbers
- Ability to utilize critical thinking skills to identify issues and required actions within an appeal
- Computer literate and proficient with Microsoft Office
- Ability to participate in and facilitate group meetings
- Ability to thrive in a fast-paced environment with constantly changing and competing priorities.
- Excellent analytical skills and the ability to provide solutions to complex problems.
- Ability to be highly transparent, ethical, and driven. Relentless attention to detail, and the ability to be a creative self-starter and team player.
- Excellent written and verbal communication skills, and interpersonal skills required.
- Willingness to work a flexible schedule