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PRIA Healthcare is seeking a Patient Access Specialist to support reimbursement and patient access services for durable medical equipment (DME) and medical device clients. You will serve as a key resource for physicians, billing and coding personnel, hospitals, and ambulatory surgical centers, helping facilitate patient access to technologies and procedures.
In this role, you will manage an assigned caseload and handle the full patient access lifecycle. Key responsibilities include: managing case loads for assigned programs; entering and reviewing new patient cases into the system database; communicating regularly with physician offices and their staff; maintaining accurate records in Salesforce to support client reporting; analyzing patient clinical data and clinical notes to determine whether medical necessity criteria are met per payer policies; reviewing multiple insurance policies to define medical necessity criteria specific to medical devices and procedures; performing benefits verification and payer discovery; preparing and submitting prior authorization and pre-service review requests; managing pre- and post-service appeal submissions; ensuring all appeal documentation is accurate, consistent, up-to-date, and compliant with SOPs and regulations; and ensuring full compliance with regulatory and company policies.
You will be measured against established KPIs based on program complexity, with metrics tracked daily, weekly, and monthly. You will work with an Executive Lead on clinical data analysis and insurance policy review tasks.
QUALIFICATIONS:
- High school diploma or equivalent (Associate's degree preferred)
- Minimum 2 years of experience in a healthcare setting, preferably in authorization or billing
- Understanding of medical terminology and insurance processes
- Excellent communication and organizational skills
- Ability to work independently and handle multiple tasks
