[Hiring] Patient Access Case Manager @Boston Scientific

Role Description

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.

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.

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.

Requirements

• Neuromodulation or 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.

Benefits

• Compensation will vary based on actual location of the position and other pertinent factors.
• Compensation for non-exempt (hourly), non-sales roles may include variable compensation from time to time (e.g., any overtime and shift differential) and annual bonus target.
• Compensation for exempt, non-sales roles may also include variable compensation, i.e., annual bonus target and long-term incentives.