Payor Specialist - LOA, SCA, Third-Party Payors - Healthcare

PRO-spectus

12d•$30 - $41•Remote

About The Position

The Payor Specialist is responsible for verifying and reverifying insurance coverage and eligibility, submitting and following up on authorization requests, and maintaining follow-up communication with insurance companies. This role verifies patient insurance benefits for specific procedure coverage, updates eligibility information, submits and follows up on authorizations and LOA/SCA requests, and requests network or payment related exceptions.

Requirements

Strong organizational skills, attention to detail, and effective task management while responding productively to changing priorities.
Remains calm and objective in emotional or stressful situations.
Learns quickly and applies innovative methods, tools, and technology to the role.
High level of self-accountability for compliance with policies, procedures, and work requirements.
Seeks advice when unsure about choosing a course of action.
Makes solid routine decisions with coaching from others.
Learns about the key drivers of the organization’s business and uses those learns in the day-to-day work.
Maintains tenacity and work focus despite obstacles or setbacks and is comfortable dealing with first-time or unusual challenges.
Adequately supports multiple products and/or programs in various treatment specialties.
Independently manages tasks and follow up responsibilities without direct guidance from management or peers.
The need to understand insurance contracts and reimbursement methodologies.
Ability to effectively navigate payment negotiations within certain rate parameters.
Strong expertise in complex insurance framework including but not limited to dual coverage, unique insurance plans, purchase orders, tiered benefits.
Conversant with medical terminology.
Expertise and knowledge of third-party payor, Medicare/Medicaid guidelines.
Computer and database management skills to efficiently and effectively manage proprietary electronic systems.
Interpersonal and communication skills to effectively deal with a variety of people, including physicians, hospital leaders, nursing staff, patients, and family members.
High school diploma with at least five years healthcare experience or Associate's Degree in healthcare-related field with three to four years of experience.

Nice To Haves

Experience with payers and Clinical Guidelines or Medical Policy is preferred.

Responsibilities

Works directly in alignment with Case Management Team to coordinate efforts and prioritize daily activities to meet deadlines.
Completes insurance benefits verification and reverification to confirm active coverage, benefit details, payor requirements, and applicable patient responsibility.
Updates eligibility information accurately and timely based on payor verification and reverification findings.
Submits authorization requests when required and performs timely follow-up through final payor determination.
Submits Letters of Agreement (LOA) and Single Case Agreements (SCA) when required and performs timely follow-up through rate negotiation, execution, or final payor determination.
Obtains timely payor determinations regarding authorizations, LOA/SCA requests, network exceptions, and other payment-related needs, and accurately records and conveys determinations to the Payor Specialist Manager/Case Management Team.
Tracks and assures compliance with payor requests for information and communicates payor requests to appropriate Payor Specialist Manager/Case Management Team as applicable.
Clearly documents and communicates authorization and LOA/SCA outcomes, applicable follow up steps, and payor requirements to the Payor Specialist Manager/Case Management Team.
Communicates out-of-network obstacles and takes proactive steps to elevate network status and optimize in-network patient benefits to the Payor Specialist Manager/Case Management Team.
Provides feedback to Payor Specialist Manager/Case Management Team as needed regarding payor guidelines, issues, and determinations discovered during communication with payors.
Ensures payor and customer satisfaction by utilizing effective communication and interpersonal skills.
Proactively follows up on pending payor correspondence to encourage priority review and expedited turnaround times.
Interprets payor documentation to ensure accuracy and translates appropriately to the Case Management Team, customer, and patient.
Follows procedures and instructions to escalate or expedite authorization and LOA/SCA review timelines to meet patient and provider treatment scheduling expectations.
Work collaboratively and cross-functionally between management and programs.
Additional duties as assigned.