Patient Access Case Manager

Patient Access Case Manager

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.

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.

This is a remote role that requires consistent working-hour alignment to normal business hours of assigned market. Boston Scientific will not offer sponsorship or take over sponsorship of an employment visa for this position at this time. Relocation assistance is not available for this position at this time.

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.

Required 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

Preferred qualifications:

• 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

The anticipated compensation listed above and the value of core and optional employee benefits offered by Boston Scientific (BSC) will vary based on actual location of the position and other pertinent factors considered in determining actual compensation for the role. Compensation will be commensurate with demonstrable level of experience and training, pertinent education including licensure and certifications, among other relevant business or organizational needs.