Senior Patient Access Appeals Specialist

Description

The Senior Patient Access Appeals Specialist responsible for various functions in support of patient access to the SPRINT PNS System including but not limited to collaborating with payers, providers, patients, field sales representatives and other functional areas within the company. 

The Senior Appeals Specialist supports the patient access program by managing, reviewing, and resolving escalated and/or external appeals. Collaborates with payers, providers, patients, sales representatives and other functional areas within the company.

PRIMARY RESPONSIBILITIES

• Prepare, submit, and track appeal documentation to insurance payers, including gathering and organizing medical records, clinical justifications, and supporting materials required for appeal submissions and hearing processes.
• Maintain accurate and detailed records of all appeal activities, hearing outcomes, and related correspondence through Salesforce. 
• Analyze trends in denials and appeal outcomes to identify opportunities for process improvement and to prevent future denials.
• Serve as a liaison between patients, providers, and payers to facilitate the appeals process, including communication and coordination with internal departments, external agencies, and legal representatives as needed
• Coordinate with providers and patients to obtain additional information needed to facilitate appeals process
• Represent patients during Administrative Law Judge (ALJ) hearings and state fair hearings, including preparing case files, presenting evidence, and providing supporting documentation as required.
• Monitor the status of appeals, ALJ hearings, and state fair hearings, ensuring all deadlines are met and follow-up actions are completed promptly
• Review and interpret clinical records to ensure patients meet medical policy guidelines for coverage for completeness and perform follow-up for additional information if necessary.
• Crafts compelling documentation and supporting evidence for SPR products.
• Maintains knowledge of SPR technology, treatment pathway and indications alongside individual patient information.
• Educate patients and staff on appeal rights, hearing processes, and required documentation, providing guidance and support throughout the appeals and hearing lifecycle.
• Assist with supporting other team members with case related tasks and submissions as workload permits. 
• Provide superior customer support to external customers, patient candidates, and the internal SPR Sales Organization
• Take ownership of initiatives to support process improvement and education gaps within the SPRcare department
• Perform other duties and projects as assigned by management

Requirements

KNOWLEDGE AND SKILL REQUIREMENTS

Experience, Competencies, Education:

• Bachelor's degree or higher level of education, preferably with a concentration in healthcare, nursing, or law.
• A minimum of 5 years of related health insurance experience in both prior authorization and patient appeals for all payer types 
• Strong knowledge of medical benefits, insurance standards, investigation processes, and compliance requirements for reimbursement for Medicare, Medicaid, Commercial, Workers Compensation, liability insurances
• Understanding of billing and payment competencies including but not limited to CPT, ICD-10, HCPCS coding, CPT modifier use, and EOB interpretation. 
• Advanced ability to locate and interpret payer coverage policies, provider manual, billing guidelines, and payment methodologies. 
• Experience with managing hearings on behalf of patients 
• Excellent written and verbal communication skills
• Advanced knowledge of complex insurance regulations and billing practices.
• High level of organization and ability to manage multiple cases simultaneously
• Exhibits independent problem solving and critical thinkings skills as well as the ability to communicate clearly and effectively both internally and externally (payers and providers).
• Experience working in a CRM platform, ideally Salesforce. Proficiency in Microsoft Office Software, email programs, and online information systems.
• Knowledge of HIPAA and related patient privacy laws

WORKING CONDITIONS

• Collaborative and committed to getting the job done in a supportive, “can-do” team environment.
• Remote or hybrid (local to Minnesota)
• Travel – less than 10%