Payor Specialist – Medical Device, Third-Party Payors

🔥 20 minutes ago

🇺🇸 United States – Remote

💵 $30 - $41 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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PRO-spectus

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2008

🏥 Healthcare

💊 Pharmaceuticals

💼 Consulting

💰 Private equity on 2024-05

Healthcare • Pharmaceuticals • Consulting

PRO-spectus is a patient access and market access services provider that helps pharmaceutical, biotech, medical device, and diagnostic manufacturers overcome reimbursement, coding, and policy barriers to getting products to patients. The firm offers patient support services, reimbursement support, policy strategy, affordability and adherence programs, and leverages technology alongside market-access expertise to optimize access across the healthcare landscape. PRO-spectus positions itself as a collaborative, B2B partner to manufacturers seeking to expand coverage and patient access to specialized therapies and diagnostics.

📋 Description

• Verify and reverify insurance coverage, eligibility, benefits, procedure coverage, payor requirements, and patient responsibility • Update eligibility information accurately and promptly • Submit and follow up on authorization requests through final payor determination • Submit and follow up on Letters of Agreement and Single Case Agreement requests through negotiation, execution, or final determination • Obtain, record, and communicate payor determinations, network exceptions, and payment-related decisions • Track compliance with payor requests for information and communicate requests to the appropriate teams • Document and communicate authorization and LOA/SCA outcomes, follow-up steps, and payor requirements • Communicate out-of-network obstacles and take steps to optimize in-network patient benefits • Provide feedback on payor guidelines, issues, and determinations • Follow up on pending payor correspondence to encourage priority review and expedited turnaround • Interpret payor documentation and translate it for the Case Management Team, customers, and patients • Escalate or expedite authorization and LOA/SCA reviews to meet treatment scheduling expectations • Coordinate daily activities with the Case Management Team and collaborate cross-functionally between management and programs • Perform additional duties as assigned

🎯 Requirements

• Strong organizational skills, attention to detail, and effective task management while responding productively to changing priorities • Ability to remain calm and objective in emotional or stressful situations • Ability to learn quickly and apply innovative methods, tools, and technology • High level of self-accountability for compliance with policies, procedures, and work requirements • Ability to support multiple products and/or programs in various treatment specialties • Ability to independently manage tasks and follow-up responsibilities • Understanding of insurance contracts and reimbursement methodologies • Ability to navigate payment negotiations within certain rate parameters • Strong expertise in complex insurance frameworks, including dual coverage, unique insurance plans, purchase orders, and tiered benefits • Conversant with medical terminology • Expertise and knowledge of third-party payor, Medicare/Medicaid guidelines • Computer and database management skills for proprietary electronic systems • Interpersonal and communication skills for working with physicians, hospital leaders, nursing staff, patients, and family members • High school diploma with at least five years of healthcare experience OR Associate's Degree in a healthcare-related field with three to four years of experience • Experience with payers and Clinical Guidelines or Medical Policy preferred

🏖️ Benefits

• Robust medical, dental, and vision plans • Life insurance and disability coverage • Tax-advantaged savings accounts • Employee Assistance Program • Home office benefits • Employee Ownership Program • Paid time off • Paid holidays • Bereavement leave • 401(k) retirement plan with employer matching • Performance-based bonus opportunity

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