The Payor Specialist Lead is responsible for verifying insurance coverage, submitting authorization requests, and maintaining follow-up communication with insurance companies. More specifically, this role serves as a subject matter expert, conducts on the job training, and assists the Payor Specialist team with escalations while working closely with program management to ensure program goals are met. Additionally, they participate in special projects and support program leadership.
Core Duties/Responsibilities:
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Supports a reduced payor specialist workload in conjunction with Team Lead responsibilities.
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Provides peer support through training and assistance navigating complex payor scenarios.
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Assists with obtaining patient access supporting prior authorization and medical necessity processes, benefit investigations, and payor network obstacles.
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Clearly documents and communicates authorization outcomes and applicable follow up steps for approval to the Payor Specialist Manager/Case Management Team
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Provides feedback to Program Leadership/Case Management Team as needed regarding payor guidelines, issues, and determinations discovered during communication with payors.
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Ensures payor and customer satisfaction by utilizing effective communication and interpersonal skills
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Proactively follows up on pending payor correspondence to encourage priority review and expedited turnaround times.
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Interprets payor documentation to ensure accuracies and translates appropriately to cross functional teams.
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Follows procedures and instructions to escalate or expedite authorization review timelines to meet patient and provider treatment scheduling expectations.
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Additional duties as assigned.
Skills / Requirements:
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Strong organizational skills, attention to detail, and effective task management while responding productively to changing priorities.
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Remains calm and objective in emotional or stressful situations.
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Learns quickly and applies innovative methods, tools, and technology to the role.
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High level of self-accountability for compliance with policies, procedures, and work requirements.
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Seeks advice when unsure about choosing a course of action.
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Makes solid routine decisions with coaching from others.
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Learns about the key drivers of the organization’s business and uses those learnings in the day-to-day work.
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Maintains tenacity and work focus despite obstacles or setbacks and is comfortable dealing with first- time or unusual challenges.
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Supports multiple products and/or programs in various treatment specialties.
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Independently manages tasks and follow up responsibilities without direct guidance from management or peers.
Education, Certifications and Experience:
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Experience with payers and Clinical Guidelines or Medical Policy is preferred.
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Conversant with medical terminology.
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Expertise and knowledge of third-party payor, Medicare/Medicaid guidelines.
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Computer and database management skills to efficiently and effectively manage proprietary electronic systems.
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Interpersonal and communication skills to effectively deal with a variety of people, including physicians, hospital leaders, nursing staff, patients, and family members.
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High school diploma with at least five years healthcare experience or Associates Degree in healthcare-related field with two years of experience.
Physical Requirements:
- As a remote-forward organization, this position operates in a professional office environment and teleworking from the employee’s home address listed in their employment file.
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Prolonged periods of sitting at a desk and working on a computer
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Keyboarding
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Speaking
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Must be able to lift up to 15 pounds at times
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Flexibility of working hours to support activities across EST to PST zones
Our PRO-Spectus Culture Philosophy
At PRO-Spectus we have created a culture that is supportive, dedicated, and teamwork driven. We celebrate each other’s joys in personal life and professional accomplishments, promoting meaningful relationships and friendships.
Our employees bring strength of mind and spirit to make the extraordinary happen every day. With humility and compassion at our core, PRO-Spectus is proud of our relentless focus towards the higher purpose of improving the lives of patients we support.
We recognize it takes a lot of people working together with a common goal to make spectacular happen, and we never forget that at the heart of our company are the people who make it work.
PRO-Spectus is an Equal Opportunity / Affirmative Action employer. All qualified individuals will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, protected veteran status, marital status or other protected status under federal, state or local laws.