Pre Authorization Specialist

About This Role

The Pre-Authorization Specialist II performs benefit verification, prior authorization, and appeal functions for the Patient Access Support Program. This role secures insurance approval for endobariatric procedures using Boston Scientific devices by working with team members, customers, and payers.

Responsibilities

• Verify medical insurance benefits and coverage, including obtaining and processing payer forms
• Submit prior authorization/pre-determination requests and internal/external appeals to health plans
• Apply pressure on health plans that refuse to review based on negative or absent coverage policy for Endobariatric procedures
• Follow up on prior authorization and appeal requests with health plans to ensure receipt and proper review for medical necessity
• Monitor and re-engage payers until final determination is made, ensuring all appeal rights are exhausted
• Answer incoming calls received through the toll-free PASP call center, providing superior customer service
• Utilize proficient knowledge in Microsoft Office and Salesforce to document case statuses, actions, and outcomes
• Communicate and build relationships with HCP offices and internal stakeholders regarding inquiries and case handling
• Maintain PASP metrics and standards
• Process incoming emails by responding and triaging inquiries appropriately
• Process incoming faxes to efficiently manage service requests and facilitate communication
• Report adverse events/product complaints following program Standard Operating Procedures (SOPs)
• Comply with SOPs to maintain data integrity
• Maintain HIPAA compliance and patient confidentiality
• Coordinate with lead regarding complicated cases

Requirements

• High school diploma
• Minimum 2 years experience working with various payers (Medicare, Medicaid, Private/Commercial, VA)
• Experience reviewing clinical records and extracting key information to support medical necessity
• Experience submitting prior authorization requests for medical procedures
• Understanding and leveraging payer coverage criteria to ensure positive outcomes
• Proficient in Microsoft Office
• Excellent written and verbal communication skills
• Ability to work independently with minimal to moderate supervision

Qualifications

• High school diploma
• Minimum 2 years relevant experience working with various payers (Medicare, Medicaid, Private/Commercial, VA), reviewing clinical records, submitting prior authorization requests for medical procedures, and understanding payer coverage criteria.

Nice to Have

• Associate’s degree
• Medical device experience and/or bariatric experience
• Experience utilizing software/systems to perform tasks (e.g., Salesforce, EMR, payer portals, Policy Reporter)
• Experience interpreting medical necessity and experimental/investigational denials and drafting appeals

Skills

* Required skills