Authorization and Appeals Specialist

Patient Services Representative: Authorizations & Appeals

For more than 20 years, BioTAB Healthcare, LLC has supported patients with lymphatic, wound, and circulatory disorders through proven treatment solutions. Headquartered in Missouri, we provide pneumatic compression devices and personalized service to help improve patient outcomes and quality of life. As a family-owned company, we take pride in delivering expert care with a personal touch service.

The Patient Services Representative position puts the Patient First in every interaction. This role will process clinical paperwork from our sales team, review coverage requirements under private health insurance, CMS and research patient benefits to obtain product approvals in order to process the patient's orders. This role will interface with patients, sales, sales leadership, clinicians and our internal teams on a daily basis, and will include both incoming and outgoing calls, emails, CRM and Provider systems, fax, email and Vendor portals. Reps will handle all documentation requirements for patient charting, shipping and cost to make the patient experience as smooth as possible. This role, reporting to the team's Managers and Directors, will require an exceptional level of detail, customer service acumen and an emphasis on process execution and quality control.

Intake will be responsible for:

• Benefits & prior-authorizations
• Appeals
• Re-certifications
• Interface with Parachute

Case processing will be responsible for:

• Case review & processing documentation
• Order review & confirmation
• Re-work
• Interface with TMs, Bonafide, calls

Key Responsibilities

• Patient Intake: Receiving and processing new patient referrals, gathering necessary demographic, medical, and insurance information. This will require outbound and inbound professional communications, interface with BPO partners and quality control measures.
• Insurance Verification: Verifying patient insurance coverage and benefits for BioTAB products, update cases accordingly for record keeping and internal Insurance Database. Verify patient benefits with insurance companies and manage utilization review activities, requests and obtain prior authorizations from insurance providers to ensure the equipment is covered.
• Coordination: Collaborating with sales, patients and their caregivers / healthcare professionals to get the patient's products covered, shipped and in use, with quality and accuracy at the forefront of every case processed. Provide administrative support as needed, including assistance with documentation, communication, and clerical tasks.
• Process Management: Answer incoming calls to services lines and provide patient support, answer questions and document interactions & resolutions in CRM. Escalate any urgent requests & direct to correct departments or Leaders.
• Communication: Maintain clear and effective communication with patients, families, and other healthcare team members. Provide strong customer service, responding quickly and appropriately to patient needs, and can manage potentially difficult or emotional situations.
• Record Management: Ensuring accurate and timely documentation of all case activities and patient information in the required system. Maintain accurate and organized records of client interactions, service plans, and case management activities. Create and manage electronic consent forms; upload signed forms to patient charts. Complete forms, produce reports on client progress and service delivery, and ensure compliance with organizational policies and regulatory requirements.
• Compliance: Ensure compliance with relevant healthcare regulations, financial standards, and internal policies. Prepares cases and escalations for Review and other regulatory agencies, assisting in monitoring compliance with Medicare regulations. Adhere to all relevant regulations and agency policies regarding patient intake and data management, including but not limited to: CMS and OFCCP guidelines related to our Quality Management System, documentation and process creation and training.
• Strong communication and interpersonal skills: To interact effectively with patients, families, and healthcare professionals. Ability to work independently and as a team member, take direction and participate in Continuous Education as required for the role.
• Excellent organizational and time management skills: To manage a high volume of tasks and ensure timely processing of information.
• Attention to detail: To ensure accuracy in patient records and insurance information. Ability to multitask and prioritize duties to support delivery of high-quality patient experience.
• Knowledge of healthcare regulations and insurance processes: To navigate the complexities of DME care.
• Problem-solving skills: To address any issues or challenges that may arise during the work process.

Required Skills & Abilities

• High School or equivalent required, associates/bachelor's degree preferred.
• 1+ years of experience in healthcare operations, customer service, or similar role or setting preferred.
• Must be able to use SalesForce or Epic, fax, email, GSuite or Office, in/outbound calls with appropriate grammar, spelling and punctuation.
• Strong communication skills, both written and verbal.
• Comfortable handling sensitive and confidential Information (HIPAA).

Job Requirements & Physical Demands

• Must be able to lift 40 pounds, must be able to lift 40 pounds from the floor and lift to waist level.
• Must be able to kneel, stoop, climb stairs and reach with hands and arms.
• Reliable work transportation.
• Candidates must pass an extensive background check.
• Strict adherence to HIPAA, Medicare Fraud, Waste, and Abuse and privacy regulations in all patient interactions.

This job description outlines essential duties but is not exhaustive. Employees may be assigned other tasks. All duties are subject to modification for disability accommodation. Successful performance requires specific skills and abilities. This document sets minimum requirements and does not imply an employment contract. The company is an equal opportunity employer, drug-free workplace, and complies with ADA regulations as applicable.