Payor Specialist - Healthcare Prior Authorizations

Job Description

Job Description

We're always looking for talented, passionate individuals to join our team!

This posting is part of our ongoing search for exceptional candidates. We maintain a pipeline of qualified candidates for current and future openings.

By applying, you'll be considered for opportunities that align with your skills and experience.

If you're driven, collaborative, and ready to make an impact, we encourage you to submit your application today to be part of our talent community.

The Payor Specialist is responsible for verifying insurance coverage, submitting authorization requests and maintaining follow-up communication with insurance companies. More specifically, this role verifies patient insurance benefits for specific procedure coverage, facilitates product related authorization/approval, and requests network or payment related exceptions.

This position will support multiple products simultaneously, requiring strong prioritization and coordination skills, and will include working through complex coverage scenarios. Experience navigating nuanced or layered coverage requirements would be valuable.

Core Duties/Responsibilities:

• Works directly in alignment with Case Management Team to coordinate efforts and prioritize daily activities to meet deadlines.
• Obtains timely payor determinations regarding certifications of needs and accurately records and conveys the determination to the Payor Specialist Manager/Case Management Team
• Tracks and assures compliance with payor requests for information and communicates payor requests to appropriate Payor Specialist Manager/Case Management Team as applicable.
• Clearly documents and communicates authorization outcomes and applicable follow up steps for approval to the Payor Specialist Manager/Case Management Team
• Communicates out-of-network obstacles and takes proactive steps to elevate network status and optimize in-network patient benefits to the Payor Specialist Manager/Case Management Team.
• Provides feedback to Payor Specialist Manager/Case Management Team as needed regarding payor guidelines, issues, and determinations discovered during communication with payors.
• Ensures payor and customer satisfaction by utilizing effective communication and interpersonal skills
• Proactively follows up on pending payor correspondence to encourage priority review and expedited turnaround times.
• Interprets payor documentation to ensure accuracies and translates appropriately to the Case Management Team, customer, and patient.
• Follows procedures and instructions to escalate or expedite authorization review timelines to meet patient and provider treatment scheduling expectations.
• Work collaboratively and cross-functionally between management and programs
• Additional duties as assigned

Skills / Requirements

• Strong organizational skills, attention to detail, and effective task management while responding productively to changing priorities.
• Remains calm and objective in emotional or stressful situations.
• Learns quickly and applies innovative methods, tools, and technology to the role.
• High level of self-accountability for compliance with policies, procedures, and work requirements.
• Seeks advice when unsure about choosing a course of action.
• Makes solid routine decisions with coaching from others.
• Learns about the key drivers of the organization's business and uses those learns in the day-to-day work.
• Maintains tenacity and work focus despite obstacles or setbacks and is comfortable dealing with first- time or unusual challenges.
• Adequately supports multiple products and/or programs in various treatment specialties
• Independently manages tasks and follow up responsibilities without direct guidance from management or peers.
• The need to understand insurance contracts and reimbursement methodologies
• Ability to effectively navigate payment negotiations within certain rate parameters.
• Strong expertise in complex insurance framework including but not limited to dual coverage, unique insurance plans, purchase orders, tiered benefits.

Education, Certifications and Experience:

• Experience with payors and Clinical Guidelines or Medical Policy is preferred.
• Conversant with medical terminology.
• Expertise and knowledge of third-party payor, Medicare/Medicaid guidelines.
• Computer and database management skills to efficiently and effectively manage proprietary electronic systems.
• Interpersonal and communication skills to effectively deal with a variety of people, including physicians, hospital leaders, nursing staff, patients, and family members.
• High School Diploma with at least 5 years of healthcare experience OR Associate's Degree in a healthcare-related field with at least 3 years of experience.

Physical Requirements:

• As a remote-forward organization, this position operates in a professional office environment and teleworking from the employee's home address listed in their employment file.
• Prolonged periods of sitting at a desk and working on a computer
• Keyboarding
• Speaking
• Must be able to lift up to 15 pounds at times
• Flexibility of working hours to support activities across EST to PST zones

Our PRO-spectus Culture Philosophy

At PRO-spectus we have created a culture that is supportive, dedicated, and teamwork driven. We celebrate each other's joys in personal life and professional accomplishments, promoting meaningful relationships and friendships.

Our employees bring strength of mind and spirit to make the extraordinary happen every day. With humility and compassion at our core, PRO-spectus is proud of our relentless focus towards the higher purpose of improving the lives of patients we support.

We recognize it takes a lot of people working together with a common goal to make spectacular happen, and we never forget that at the heart of our company are the people who make it work.

PRO-spectus is an Equal Opportunity / Affirmative Action employer. All qualified individuals will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, protected veteran status, marital status or other protected status under federal, state or local laws.

At PRO-spectus, we are deeply committed to pay transparency and equity. The salary range for this position is $30 - 41 per hour , based on experience and qualifications, with the final offer reflecting skills and other job-related factors. Beyond competitive pay, we offer a comprehensive and generous benefits package designed to support your well-being and work-life balance.