Prior Authorization & Appeals Specialist

What we are looking forOptime Care seeks a Prior Authorization and Appeals Specialist for our Earth City, MO location. We are looking for someone who is passionate about helping people get the specialized therapies they need. This critical role manages the process of receiving, researching, and resolving prior authorizations and appeals issues with health insurance companies, including any escalated steps of the appeals process, following federal regulatory requirements and policies and procedures. This position will be required to be in the office for their scheduled time, Monday through Friday, during regular business hours.

The job detailsEnsure prior authorizations and appeals cases follow current guidelines and timeliness criteria, including communicating directly with providers and insurance companiesDocument all activities of the Prior Authorizations and Appeals processRespond to Prior Authorization denials and submit appeals, collecting appropriate clinical support to substantiate the formal response.

Compose technical denial arguments for reconsideration, both written and verbalOvercome objections that prevent payment of claims and gain commitment for payment through a concise and effective appeal argumentIdentify problem payors, processes, and trends and escalate where appropriateUtilize documentation standards that support a strong historical record of actions takenWrite and complete final editing of letters of determination sent out for appealsProduce and manage inbound and outbound correspondence in a manner that meets required timeframesWorks collaboratively and cross-functionally with other departments to facilitate appropriate resolutionsPrepare case files for Independent Review Entities or other levels of the Appeals processAssist with internal and external audit processesWork with assigned clients to assess trends around payer responsesParticipate in the development and completion of individual and departmental initiativesPerforms other related duties as assigned or as necessary; remains flexible and adaptable in work schedules and work assignments as defined by departmental and organizational needsNecessary Skills, Education & AbilitiesA high school diploma or equivalent is required2 or more years of experience with medical/pharmacy insurance verification, including benefit investigationKnowledge of prior authorizations and claim appeals is necessaryKnowledge of medical terminology is requiredCurrent Missouri BOP Pharmacy Technician license Knowledge of medical/pharmacy insurance benefits language, such as EOBs, deductibles, Out-of-pocket, coinsurance, co-pays, etcAbility to work independently with limited supervisionEffectively meet established productivity, schedule adherence, and quality standardsAbility to define CMS 1500s, provider numbers, CPT, HCPC’s, ICD9, NCPDP and NDC codes/numbersRelentless attention to detail and the ability to be a creative self-starter and team playerAbility to utilize critical thinking skills to identify issues and required actions within appealsComputer literate and proficient with Microsoft OfficeAbility to participate in and facilitate group meetings.

Ability to thrive in a fast-paced environment with constantly changing and competing prioritiesExcellent analytical skills and the ability to provide solutions to complex problemsAbility to be highly transparent, ethical, and driven. Excellent written and verbal communication skills, and interpersonal skills requiredWillingness to work a flexible schedule to support different time zones across the countryAbout UsOptime Care is a Specialty Pharmacy dedicated to providing services to smaller patient communities. We focus on securing insurance coverage, coordinating care, and complying with therapy regimens are only a few examples. Our mission is to minimize the daily impact of living with unique disorders.

After just one call, our experts begin to address everything from medication delivery and insurance reimbursement to compliance and education. Every patient receives a proactive service experience tailored to their specific needs. Optime Care provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. Powered by JazzHRUduO4IeyFS