Post-Service Appeals Case Manager

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Noctrix Health, Inc.

WebsiteLinkedInAll Job Openings

11 - 50 employees

Founded 2018

🏥 Healthcare

💼 Consulting

🍽️ Food & Beverage

Healthcare • Consulting • Food & Beverage

Noctrix Health, Inc. is a pioneering company focused on developing next-generation, clinically validated wearable therapeutics aimed at managing chronic neurological disorders. With a mission to address the unmet needs of individuals living with such conditions, Noctrix combines expertise from seasoned medical device experts, neuroscientists, and engineers to deliver innovative therapies that enhance user experience. The company's flagship product, Nidra, has received FDA Breakthrough Device Designation and is designed for conditions like Restless Legs Syndrome, representing a promising advancement in wearable health technology.

📋 Description

• Independently manage post-service medical necessity appeals for DME claims from initial denial review through final resolution • Review denied claims, denial rationale, documentation deficiencies, authorization issues, and appeal strategies • Review medical records and clinical documentation to assess medical necessity and payer coverage criteria • Research and interpret payer policies, medical necessity guidelines, coverage criteria, reimbursement requirements, and appeal procedures • Prepare and submit first-level, second-level, and other applicable appeals within deadlines • Draft clear, clinically supported appeal letters addressing denial rationale and medical necessity • Obtain missing clinical documentation from healthcare providers and clinical teams • Communicate with insurers, payer representatives, and claims departments about appeals and determinations • Track submissions, correspondence, follow-ups, deadlines, decisions, and outcomes • Maintain accurate case notes and patient information in CRM, billing, and case management systems • Apply knowledge of benefit investigations, prior authorizations, retro-authorizations, claims workflows, and appeals • Partner with Billing and Reimbursement teams on appeal status and next steps • Support prior authorization and other reimbursement appeals as needed • Identify denial trends and documentation deficiencies; report findings and process-improvement opportunities • Provide leadership reporting on denials, appeal outcomes, payer trends, and process improvements • Educate providers and internal stakeholders on documentation requirements and denial reasons • Collaborate with Patient Access, Reimbursement, Billing, Clinical, and cross-functional teams • Develop and maintain payer resources, appeal templates, tools, and training materials • Meet quality, accuracy, productivity, and turnaround-time expectations • Maintain patient confidentiality and comply with company policies, HIPAA, and privacy requirements

🎯 Requirements

• Bachelor’s degree in Business, Healthcare Administration, Health Sciences, or related field preferred; equivalent relevant experience considered • Minimum 5 years of healthcare industry experience, preferably in medical device, DME, reimbursement, patient access, billing, or related functions • Minimum 2 years of medical device reimbursement experience involving DME products • Experience managing post-service appeals, claim denials, or medical necessity appeals • Understanding of DME reimbursement, benefit investigations, prior and retro-authorizations, claims processing, and appeals • Ability to research and interpret payer policies, medical necessity criteria, coverage requirements, and appeal procedures independently • Experience reviewing clinical documentation and assessing medical necessity support • Ability to independently prepare, submit, track, and follow up on complex appeals • Understanding of payer deadlines and timely, accurate submissions • Strong analytical and problem-solving skills for complex claims issues • Excellent written communication skills for clear, persuasive, clinically supported appeal documentation • Excellent verbal communication and collaboration skills • Strong organizational and case management skills; ability to manage high-volume workload and multiple deadlines • Strong attention to detail and commitment to documentation accuracy and compliance • Preferred: direct post-service DME appeal experience, multi-level payer review, commercial and government payers, payer medical policies, retro-authorization, denial trend analysis, CRM/billing/case management systems, Salesforce, cross-functional healthcare collaboration, payer resources/templates/training documentation, and high-growth medical device or healthcare organizations