Authorization Appeal Specialist

Össur

4d•$29 - $31

About The Position

The Authorization Denial Appeal Specialist is responsible for managing and appealing denied prior authorizations for orthotic and prosthetic (O&P) devices across U.S ForMotion Clinics. This role partners closely with patients, clinicians, prescribing physicians, and payers to obtain required documentation, prepare comprehensive appeal submissions, and guide cases through payer review processes. The Specialist independently researches payer policies, develops case specific appeal strategies, submits complete appeal packages, and communicates appeal status through final determination.

Requirements

Ethical Conduct
Computer Proficiency
Demonstrates excellent people skills with the ability to interface with patients, physicians, and coworkers in a tactful, informed and service-oriented manner.
Detailed oriented.
Experience coordinating and participating in Peer to Peer (P2P) reviews.
Familiarity with Medicare, Medicaid, and commercial payer policies as they relate to O&P services.
Ability to interpret complex payer policy language and apply it to clinical scenarios.
Strong analytical, problem solving, and critical thinking skills.
Professional, patient centered communication style.
Ability to balance patient advocacy with payer compliance and regulatory requirements.
Bachelor’s degree in business, healthcare, or related field or equivalent combination of education and experience required.
2+ years of experience in the O&P industry utilizing EMR systems.
Prior experience and working knowledge of Commercial, Medicare, & Medicaid Insurances including authorizations, appeals/denials.
Proficient with Microsoft Office, Opie/Nymbl EMRs, ICD10 coding, medical terminology

Responsibilities

Manage end to end appeal workflows for denied prior authorizations related to orthotic and prosthetic devices.
Collaborate with patients, clinicians, and prescribing physicians to obtain medical records, clinical notes, letters of medical necessity, and other supporting documentation required for appeals.
Obtain, track, and maintain signed Appointment of Representative (AOR) forms from patients to enable payer communication.
Research payer manuals, coverage guidelines, medical policies, and provider portals to identify denial rationale and appeal requirements.
Develop customized, case by case appeal strategies based on clinical justification, payer policy, and documentation standards.
Draft clear, comprehensive, and payer specific appeal letters supporting medical necessity and policy alignment.
Compile and submit complete appeal packages through payer portals, fax, mail, or other required submission channels.
Monitor appeal status through payer systems and follow up as needed to ensure timely review and resolution.
Coordinate and participate in Peer to Peer (P2P) reviews when required, including preparation of supporting materials and scheduling with clinicians or prescribing physicians.
Proactively communicate appeal status, updates, approvals, and denials to both the patient and the clinic throughout the review process.
Track appeal deadlines, determinations, and outcomes to ensure compliance with payer timelines.
Maintain accurate, compliant documentation in EMR systems and internal tracking tools.
Provide non-managerial guidance and subject matter support to peers regarding authorization and appeal processes.
Ensure strict adherence to HIPAA and other legal and ethical standards in the handling of protected health information.