Lead Pre Authorization Specialist Boston Scientific Corporation

• 3.9 Marlborough, MA Job Details $23.45
• $39.85 an hour 9 hours ago Benefits Visa sponsorship Health insurance Qualifications 6 years Bariatrics Salesforce Microsoft Office High school diploma or GED Analysis skills Organizational skills Senior level Associate's degree Drafting Time management Full Job Description Work mode: Remote in Country Onsite Location(s): Marlborough, MA, US, 01752 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 Lead Pre Authorization Specialist is the team lead of the Patient Access Support Program (PASP), performing expert benefit verification, prior authorization, and appeal functions. This position will work closely with PASP team members, internal and external customers, and payers to secure insurance approval for endobariatric procedures using Boston Scientific devices. This role is a subject matter expert, focusing on identifying and overcoming challenges in the patient access program and reimbursement landscape. Visa Sponsorship Boston Scientific will not offer sponsorship or take over sponsorship of an employment visa for this position.

Your responsibilities will include:

Act as a subject matter expert and operational lead, always exercising sound judgment and effective communication, and providing day-to-day operational assistance to Pre-Authorization Specialists as it relates to insurance coverage policies, prior authorization and appeal processes, PASP program workflow, and best practices Utilizing billing and coding expertise, perform efficient analysis of denied claims, identifying reason(s) for denial and potential for successful resubmission, redetermination, or appeal through current coding and regulatory guidelines, payer guidelines, and clinical criteria Monitor payer trends as it relates to approvals/denials and communicate trends to the manager and team Verify medical insurance benefits and coverage, including the ability to obtain and process payer forms Submit prior authorization/pre-determination requests, and internal and external appeals to health plans to assist the team in achieving identified goals and objectives Apply pressure on health plans that refuse to review based on negative or absent coverage policy for Endobariatric procedures (i.e., Endoscopic Sleeve Gastroplasty, Transoral Outlet Reduction Endoscopy) Follow up on prior authorization and appeal requests to health plans to ensure receipt and proper review for medical necessity Draft letters for internal and external appeal Monitor and re-engage payer until final determination is made, ensuring each available level of appeal is used and all appeal rights are exhausted Confirm accuracy of authorization approval details, ensuring all codes are captured and the place of service, rendering physician, and surgery date are accurate Utilize proficient knowledge in Microsoft Office and Salesforce to document case statuses, actions, and outcomes in a timely and accurate manner Mediate high priority and escalated calls with customers in providing front line support for immediate resolution and assistance Pro-actively communicate, educate/train, implement, drive and support workflow enhancements and efficiencies Assist manager with the development of training material Assist manager with quality assurance review, auditing, call monitoring, and coaching of staff Develop and monitor reports on PASP metrics and KPIs; lead projects as directed Answer incoming calls received through the toll-free PASP call center, providing superior customer service and appropriate call/case handling Report adverse events/product complaints following program Standard Operating Procedures (SOPs) Comply with SOPs to maintain data integrity Monitor the inbound email queue, responding and triaging inquiries, ensuring all correspondence is handled timely and appropriately Monitor the departmental fax queue to coordinate the intake of requests for services and action communication from customers, patients, and payers appropriately, ensuring all correspondence is handled timely and appropriately Maintain HIPAA compliance and patient confidentiality Engage and commit to the organization's culture of continuous improvement by actively participating, supporting, and promoting BSC Mission and Values Other duties as assigned Required qualifications: High School Diploma 6+ years of relevant experience including: Two of those years must include experience in denied claims mitigation with both Government and Commercial insurance plans Working with various payers including, Medicare, Medicaid, Private Commercial, and VA Submitting prior authorization requests for medical procedures Interpreting procedure denials and drafting appeals Understanding and leveraging payer coverage criteria to ensure positive outcomes Utilizing software/systems to perform tasks (e.g., Microsoft Office, Salesforce, EMR, payer portals, Policy Reporter) In-depth knowledge of reimbursement procedures, revenue cycle processes, health insurance claims, billing and coding, and related State, Federal, and Medicare regulations Ability to analyze complex data sets and perform extensive audits to identify problems, trends, and potential risk/compliance issues Strong analytic, time management, and organization skills, with high attention to detail Ability to work independently with minimal supervision Travel