Prior Authorization and Appeals Specialist

AscellaHealth•Berwyn, PA

4h•Hybrid

About The Position

We're seeking a Prior Authorization and Appeals Specialist to join our dynamic team at AscellaHealth, where your expertise will directly contribute to improving health outcomes for patients with complex, chronic conditions and rare diseases. This role offers the opportunity to champion patient care by expertly navigating the process of receiving, researching, and resolving prior authorizations and appeals issues with health insurance companies. This includes any escalated step of the appeals process, following federal regulatory requirements and policies and procedures. This role will be based at our AscellaHealth office in Berwyn, PA, and will require being in the office 5 days a week, Monday through Friday, for the first 90 days for training purposes. After that, it will be a hybrid role that requires in-office work three (3) days per week. Apply now and join AscellaHealth - Where Innovation Meets Patient Care!

Requirements

Knowledge of Medicare, Medicaid, Commercial, PBM, and Medical billing
2 or more years of claim appeals (including processing) experience
Knowledge of medical terminology required
Knowledge of medical/pharmacy insurance benefit language- ie. EOBs, deductibles, out-of-pocket, co-insurance, co-pays, etc.
Sharp critical thinking skills to identify issues and develop strategic solutions within the appeals process
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, 1CD9, NCPDP, and NDC codes/numbers
Having a mindset of continuous improvement
Having the knowledge to understand the impact of the regulatory requirements on departmental procedures (id: CMN, state and federal requirements, etc.
Having an effective interpersonal skillset and customer service focus; ability to effectively and professionally interact with individuals at all levels of the organization as well as external parties
Goal-oriented approach with the ability to set realistic objectives, track progress, and adapt to changing priorities
Ability to work effectively in a collaborative, open environment
Strong analytical mindset to assess risks and maintain high performance and quality standards
Ability to determine appropriate levels of escalation and mitigation for identified risks
Team motivation abilities to inspire quality work under tight deadlines while managing multiple projects simultaneously
Transparent, honest communication style that builds trust and drives results
Willingness to remain available and approachable
Strong attention to detail and the ability to be a creative self-starter and team player
Computer literate and proficient with Microsoft Office
Ability to participate in and facilitate group meetings
Must be able to effectively multitask and work in a fast-paced environment, with the ability to prioritize competing tasks
Excellent analytical skills and the ability to provide solutions to complex problems
Ability to be highly transparent, ethical, and driven
Excellent written and verbal communication skills and interpersonal skills are required
Willingness to work a flexible schedule
A high school diploma or equivalent is required.
2 or more years of experience with medical/pharmacy insurance verification, including benefit investigation.

Nice To Haves

Pennsylvania Pharmacy Tech license strongly preferred but not required

Responsibilities

Produce and manage inbound and outbound correspondence in a manner that meets required timeframes.
Ensure appeals cases follow current CMS guidelines and timeliness criteria, including 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 Appeals process in the approved business standardized format.
Compose technical denial arguments for reconsideration, both written and telephonically.
Overcome objections that prevent payment of claims and gain commitment for payment through concise and effective appeal arguments.
Identify problem payors, processes, trends, and escalate as appropriate.
Utilize effective documentation standards that support a strong historical record of actions taken.
Support the internal and external audit process, as needed.
Attend and participate regularly in Appeals Department meetings.
Proactively identify areas of improvement for yourself and the department.
Participate in the development and completion of individual and departmental initiatives.
Work collaboratively and cross-functionally with other departments to facilitate appropriate resolutions.
Write and complete the final editing of letters of determination sent out for appeals.
Respond to Prior Authorizations denials and submit appeals, collecting appropriate clinical support to substantiate the formal response.
Arrange all necessary documents and materials for Prior Authorizations and Appeals, as needed.
Research external websites relating to therapy areas.
Professionally utilize sound judgement, technical knowledge, and communication skills.
Serve as a mentor for new team members.
Perform other related duties as assigned or as necessary; remains flexible and adaptable in work schedules and work assignments as defined by departmental and organization needs.