Patient Access Specialist

PRIA Healthcare Management LLC•Farmington, CT

13d•$26 - $32

About The Position

The Patient Access Specialist supports a client’s reimbursement needs to facilitate patient access to its technologies and procedures. The role serves as a resource for patient access services, including benefits verification, prior authorization, pre-service appeals, and post-service claims appeals. The position supports client company representatives and their customers, including physicians, billing and coding personnel, hospitals, and ambulatory surgical centers. The specialist manages patient cases and completes the patient access process according to program standard operating procedures. This includes entering and reviewing case information, communicating with physician offices, maintaining accurate Salesforce records, and assisting with analysis of clinical documentation and payer policies to support medical necessity determinations and appeals. The role also follows applicable regulatory requirements and company policies. Performance indicators are established according to program complexity and success measures, and are monitored daily, weekly, and monthly.

Requirements

High school diploma or equivalent.
At least 2 years of experience in a healthcare setting, preferably in authorization or billing.
Understanding of medical terminology and insurance processes.
Excellent communication and organizational skills.
Ability to work independently and handle multiple tasks.

Nice To Haves

Associate’s degree preferred.

Responsibilities

Manage a caseload for an assigned program.
Enter and review new patient cases in the system database.
Communicate regularly with physician offices and their staff.
Maintain accurate, up-to-date records in Salesforce for accurate client reporting.
Complete the patient access process according to program SOPs, including benefits verification and payer discovery.
With assistance from the Executive Lead, analyze and interpret patient clinical data, notes, and files to determine whether payer-specific medical necessity criteria are met.
With assistance from the Executive Lead, review insurance policies to identify medical necessity criteria for medical devices and procedures.
Submit prior authorization and pre-service review requests, as well as pre- and post-service appeals.
Ensure appeal-supporting documents are accurate, consistent, current, and compliant with applicable SOPs, guidelines, and regulations.
Ensure compliance with regulatory requirements and company policies.
Meet program KPIs, which are established according to program complexity and success and measured daily, weekly, and monthly.