Market Access Specialist (Prior Auth and Appeals)

SetPoint Medical’s Market Access Specialist will facilitate patient access to support the launch of the first neuroimmune modulation therapy to treat rheumatoid arthritis in the US. As the first non-pharmacologic treatment for rheumatic disease, this disruptive technology has the potential to improve the lives of people living with chronic autoimmune disorders. This role will manage the pre-service clearance and prior authorization process for patients seeking access to SetPoint Therapy. This will include engagement with patients, rheumatology providers, neurosurgery practices, and hospitals to ensure a smooth pre-service clearance process. This position is remote and will report to the Senior Manager of Market Access. Job Responsibilities Provide excellent customer support to providers and HCO support staff, patients, and internal teams. Review and log incoming medical record documentation, providing feedback to providers where necessary. Verify medical benefits and facilitate the prior authorization process for company products. Coordinate the pre-service appeals process, including composition of appeals. Establish strong relationships with referring rheumatology practices, neurosurgery providers, hospitals and health systems to deliver best-in‑class prior authorization services. Identify payer behaviors, actions and trends that inform prior authorization approach. Complete corporate administrative and training requirements on time and accurately. Maintain company standards involving ethical and moral character and always represent the company with the highest professional standards. Minimum Qualifications At least 2 years’ experience working in prior authorization and/or a pre‑service clearance function at a medical device/pharmaceutical company, healthcare provider, or third‑party market access service provider. Excellent interpersonal communication skills. Skilled in appeal composition and/or persuasive writing. Understanding of medical practice management, specifically related to prior authorization portals, NPIs, electronic health records and patient/provider releases. Knowledge of the prior authorization appeal processes that include external review, state fair hearing, and ALJ. Awareness of State and Federal laws that impact patient and provider appeal rights, external review protocols and URAC standards. Experience with HIPAA compliance standards for covered entities. Understanding of Prior Authorization workflows and ability to learn and use IT systems such as Salesforce, EPIC, Cerner, etc. Preferred Qualifications Ability to work independently. Ability to manage complexity and re‑prioritize work efforts to drive efficiency and outcomes. Ability to understand trends, identify issues, and develop corrective actions. Ability to thrive in a fast‑paced, dynamic startup environment, with a willingness to adapt to changing priorities and market conditions. Passion for improving patient outcomes and a commitment to the company’s mission and values. Physical Requirements Ability to perform routine physical tasks, including lifting to 20 pounds. Prolonged periods of sitting at a desk and working on a computer. Work Location and Travel This position will require occasional travel up to 10%, including travel to Company Headquarters in Valencia, CA. Company Description SetPoint Medical is a commercial‑stage medical technology company dedicated to improving care for people living with chronic autoimmune diseases. Department: Market Access Reports To: Sr. Manager Market Access FLSA Status: Exempt Location: Remote In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification form upon hire. Candidates must have and maintain authorization to work within the United States as a condition of employment. We are proud to be an equal opportunity employer and we value diversity. SetPoint does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, disability, national origin, veteran status or any other basis covered by appropriate law. All employment is decided on the basis of qualifications, merit, and business need. #J-18808-Ljbffr SetPoint Medical