Patient Access Case Manager- Medical Device

Moximed, Inc.; United States; On-site; USD 55,000 - 75,000; Full time

Job summary

Moximed, Inc. is seeking a detailed-oriented Case Manager to join our Patient Access team. The Case Manager handles insurance authorization and appeals, coordinating with physicians and patients to navigate the reimbursement landscape.

You will manage up to 150 cases, submit prior authorizations, draft appeal letters, and monitor payer trends to ensure timely decisions. Strong organization and communication are essential, as is experience with prior authorization processes and Salesforce.

Qualifications

• 3+ years’ experience in prior authorization and appeals management.
• Experience submitting prior authorization requests for medical procedures and interpreting procedure denials to draft appeals.
• Understanding and leveraging payer coverage criteria to ensure positive outcomes.
• 3+ years utilizing software systems to perform tasks, Salesforce preferred.
• High school diploma.

Responsibilities

• Submit and follow up on prior authorization requests to health plans.
• Persuasively engage health plans that are unwilling to review prior-authorization(s).
• Draft letters for appeal, external review, and administrative law judge hearings.
• Monitor and re-engage payer until final determination is made and all appeal rights are exhausted.
• Document all case-related communication to physicians, patients, and payers with chronology.
• Confirm accuracy of authorization approval details within approved timeframes prior to surgery.
• Monitor payer trends as it relates to approvals/denials and communicate trends to leadership.
• Communicate case status and required information to internal and external customers.
• Act as a resource for team members and new employees.
• Prioritize tasks according to urgency.
• Maintain a case volume up to 150 cases at a time.

Skills

Prior authorization

Appeals management

Payer criteria interpretation

Salesforce

Education

High school diploma

Tools

Salesforce

Job description

Moximed, Inc. is seeking a detailed-oriented and organized Case Manager to join our Patient Access team. The Patient Access Case Manager is responsible for managing patient cases through the insurance authorization and appeal process. This role involves close collaboration with team members and external customers, including physicians and patients, to navigate obstacles in the patient access program and reimbursement environment.

B. Responsibilities

• Submit and follow up on prior authorization requests to health plans to ensure receipt and proper review for medical necessity.
• Persuasively engage health plans that are unwilling to review prior-authorization(s) based upon negative or absent coverage policy for MISHA.
• 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.
• Document all case-related communication and activity to physicians, patients, and payers in a clear and concise 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 leadership.
• Clearly communicate with internal and external customers regarding patient access to MISHA, 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.
• Maintain a case volume up to 150 cases at a time.

JOB REQUIREMENTS:

A. Education and Training

• 3+ years’ experience in prior authorization and appeals management
• Experience submitting prior authorization requests for medical procedures and interpreting procedure denials to draft appeals
• Understanding and leveraging payer coverage criteria to ensure positive outcomes
• 3+ years utilizing software systems to perform tasks, Salesforce preferred
• High school diploma

B. Other Requirements

• <10% Travel

WHO WE ARE:

Moximed has built a team where innovation meets freedom for patients! Since the beginning, an entrepreneurial mindset and making patient care our number one priority has always guided our approach to work and the environment we create.

Our unique culture of empathy, enthusiasm, trust in each other, and resilience reflects our responsibility to our patient and our team. We organize around goal focused teamwork and transparent accountability to achieve our successes. we foster a culture of inclusion and belonging where all perspectives, abilities and experiences are valued and our people can reach their potential and truly thrive.

If you are a motivated, forward thinking, and creative person who is excited about transforming lives then Moximed might be a great fit for you.

At Moximed we believe that the unique contributions of all our team members create our success. To ensure that our culture continues to incorporate everyone’s perspectives and experience, we never discriminate based on race, religion, national origin, gender identity or expression, sexual orientation, age, marital, veteran, or disability status