Patient Access Case Manager

Boston Scientific-posted about 1 year ago

Part-time • Mid Level

Remote • Minneapolis, MN

1,001-5,000 employees

Miscellaneous Manufacturing

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The Patient Access Case Manager is responsible for managing patient cases through the insurance authorization and appeal process, working closely with team members and external customers to navigate obstacles in the patient access program and reimbursement environment.

Follow up on prior authorization requests to health plans to ensure receipt and proper review for medical necessity.
Apply pressure on health plans that refuse to review based on negative or absent coverage policy for Intracept.
Accurately identify payer denial reasons and develop an action plan for appeal.
Draft letters for appeal, external review, and administrative law judge hearings.
Monitor and re-engage payer until final determination is made, ensuring all appeal rights are exhausted.
Participate in administrative law judge hearings via phone, presenting on behalf of the Medicare Advantage patient.
Submit prior authorization requests to health plan as needed to assist the team in achieving identified goals and objectives.
Draft all case-related communication to physicians, patients, and payers in a clear and concise manner.
Document all case activity and correspondence for cases in a timely and accurate manner to provide chronological details of case progress.
Confirm accuracy of authorization approval details, ensuring all codes are captured and authorization is within approved timeframes prior to surgery.
Manage and monitor payer trends as it relates to approvals/denials and communicate trends to the team.
Clearly communicate with internal and external customers regarding patient access to Intracept Procedure, including case status, needed information, TM involvement, reporting, etc.
Act as a resource for fellow team members and new employees.
Prioritize tasks according to urgency.

2+ years' experience in a pain management/spine prior authorization role.
Experience in reviewing clinical records and extracting key information to support medical necessity.
Experience in submitting prior authorization requests for medical procedures.
Experience in interpreting procedure denials and drafting appeals.
Understanding and leveraging payer coverage criteria to ensure positive outcomes.
2+ years utilizing software systems to perform tasks.

Neuromodulation/Basivertebral nerve ablation experience.
Ability to communicate clearly and assertively with payers.
Strong written and verbal communication skills.
Software experience, i.e. EMR, payer portals, Microsoft Office, Salesforce.

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