Patient Access Case Manager

Davita Inc.; Santa Clarita (CA); Remote; USD 63,000 - 73,000; Full time

Job summary

A leading healthcare company seeks a Patient Access Case Manager to manage insurance authorization and appeals. The role involves working closely with patients and physicians to facilitate access to treatments, drafting appeals, and ensuring compliance with medical necessity criteria. Ideal candidates have experience in pain management and strong communication skills.

Qualifications

• 2+ years in pain management or spine authorization.
• Experience in reviewing clinical records and drafting appeals.
• Ability to communicate clearly with payers.

Responsibilities

• Manage patient case through insurance authorization process.
• Draft letters for appeals and monitor payer communications.
• Ensure all appeal rights are exhausted.

Skills

Communication

Analytical Thinking

Problem Solving

Education

High School Diploma

Tools

EMR

Microsoft Office

Salesforce

Job description

Additional Location(s): N/A

Diversity - Innovation - Caring - Global Collaboration - Winning Spirit- High Performance

At Boston Scientific, we'll give you the opportunity to harness all that's within you by working in teams of diverse and high-performing employees, tackling some of the most important health industry challenges. With access to the latest tools, information and training, we'll help you in advancing your skills and career. Here, you'll be supported in progressing - whatever your ambitions.

About the role:

The Patient Access Case Manager is responsible for managing the patient case through the insurance authorization and appeal process. This position will work closely with Interventional Spine team members and external customers (physicians and patients) to identify and overcome obstacles in the patient access program and reimbursement environment.

Work Mode

This role follows a remote work mode. Qualified candidates from any location in the United States will be considered.

Visa Sponsorship

Boston Scientific will not offer sponsorship or take over sponsorship of an employment visa for this position.

Your responsibilities will include:

• 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 each available level of appeal is used and 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 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 but not limited to (case status, needed information, TM involvement, reporting etc.).


• Act as a resource for fellow team members and new employees.


• Prioritize tasks according to urgency:




• Expected Total case volume 140-160

Required qualifications:

• 2+ years of experience in a pain management or spine prior authorization role. Experience must include:
  
  
  
  • Reviewing clinical records and extracting key information to support medical necessity
  
  
  • Submitting prior authorization requests for medical procedures
  
  
  • Interpreting procedure denials and drafting appeals
  
  
  • Understanding and leveraging payer coverage criteria to ensure positive outcomes
  
  
  
  


• 2+ years of experience utilizing software systems to perform tasks


• Travel < 5%


• 40-hour work week


• Ability to sit/stand at a workstation 8 hours per day


• High school diploma

Preferred qualifications:

• 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

Requisition ID:607856

Minimum Salary:$63,000

Maximum Salary: $73,000

The anticipated compensation listed above and the value of core and optional employee benefits offered by Boston Scientific (BSC) - see www.bscbenefitsconnect.com--will vary based on actual location of the position and other pertinent factors considered in determining actual compensation for the role. Compensation will be commensurate with demonstrable level of experience and training, pertinent education including licensure and certifications, among other relevant business or organizational needs. At BSC, it is not typical for an individual to be hired near the bottom or top of the anticipated salary range listed above.

Compensation for non-exempt (hourly), non-sales roles may also include variable compensation from time to time (e.g., any overtime and shift differential) and annual bonus target (subject to plan eligibility and other requirements).

Compensation for exempt, non-sales roles may also include variable compensation, i.e., annual bonus target and long-term incentives (subject to plan eligibility and other requirements).

For MA positions: It is unlawful to require or administer a lie detector test for employment. Violators are subject to criminal penalties and civil liability.

As a leader in medical science for more than 40 years, we are committed to solving the challenges that matter most - united by a deep caring for human life. Our mission to advance science for life is about transforming lives through innovative medical solutions that improve patient lives, create value for our customers, and support our employees and the communities in which we operate. Now more than ever, we have a responsibility to apply those values to everything we do - as a global business and as a global corporate citizen.

So, choosing a career with Boston Scientific (NYSE: BSX) isn't just business, it's personal. And if you're a natural problem-solver with the imagination, determination, and spirit to make a meaningful difference to people worldwide, we encourage you to apply and look forward to connecting with you!

At Boston Scientific, we recognize that nurturing a diverse and inclusive workplace helps us be more innovative and it is important in our work of advancing science for life and improving patient health. That is why we stand for inclusion, equality, and opportunity for all. By embracing the richness of our unique backgrounds and perspectives, we create a better, more rewarding place for our employees to work and reflect the patients, customers, and communities we serve.

Boston Scientific Corporation has been and will continue to be an equal opportunity employer. To ensure full implementation of its equal employment policy, the Company will continue to take steps to assure that recruitment, hiring, assignment, promotion, compensation, and all other personnel decisions are made and administered without regard to race, religion, color, national origin, citizenship, sex, sexual orientation, gender identify, gender expression, veteran status, age, mental or physical disability, genetic information or any other protected class.

Please be advised that certain US based positions, including without limitation field sales and service positions that call on hospitals and/or health care centers, require acceptable proof of COVID-19 vaccination status. Candidates will be notified during the interview and selection process if the role(s) for which they have applied require proof of vaccination as a condition of employment. Boston Scientific continues to evaluate its policies and protocols regarding the COVID-19 vaccine and will comply with all applicable state and federal law and healthcare credentialing requirements. As employees of the Company, you will be expected to meet the ongoing requirements for your roles, including any new requirements, should the Company's policies or protocols change with regard to COVID-19 vaccination.