Sr Prior Authorization Specialist

This position is based out of our San Diego, CA office.

Mainstay Medical

Mainstay Medical is a medical device company focused on marketing an innovative implantable neurostimulation system, ReActiv8®, for people with disabling chronic mechanical Low Back Pain. The company is headquartered in Dublin, Ireland, with subsidiaries operating in the United States, Australia, the United Kingdom, and Germany.

The Role :

The Prior Authorization Specialist is primarily responsible for facilitating pre-service authorization and appeal submissions to insurance companies and external review organizations to obtain coverage for the ReActiv8 Neurostimulation System. This role will also work with other Prior Authorization Specialists on complex issues where analysis of situations requires an in-depth evaluation of variable factors.

Position Responsibilities :

Handle receipt and data entry of incoming prior authorization requests, including patient consent forms and patient medical records, promptly.

Review and ensure all necessary documentation are provided to file a prior authorization, a pre-service appeal, or an external review, when necessary.

Gather required / additional supporting documentation and information, including state protocols, physician or hospital medical records, state or federal statutes, patient, or physician letters of medical necessity, etc.

Complete eligibility and verification of patient benefits and coverage for ReActiv8, manually and / or electronically.

Submit requests to insurance companies for prior authorizations and internal pre-service appeals with collected clinical materials, letters, and reference materials for ReActiv8.

Submit requests to independent review organizations for external review appeals with collected clinical materials, letters, and reference materials for ReActiv8.

Follow through with payer correspondence and requests for more information related to each authorization and appeal submission.

Conduct informative and educational interactions with utilization review and management departments at insurance companies and independent review organizations.

Communicate with physician offices and staff / clinical contacts on the progress of their prior authorization or internal appeal requests.

Provide hard-copy authorization documents to physicians and respective facilities to support scheduling implantation for ReActiv8.

Understand and track adverse denial trends and continue to keep up to date on payer policies, regulations, and regional requirements.

Understand and work on complex issues where analysis of situations requires an in-depth evaluation of variable factors.

Frequesntly collaborate with other PAS and MML team members on complex matters as a subject matter expert

Maintain a focus on opportunities for development and improvement.

Support new hire trainingand development providing education and mentorship to new PAS team members

Deliver exceptional customer service to our customers, including physician offices, their clinical staff, patients, and field sales personnel.

Manage multiple priorities and deadlines successfully, while handling stressful situations accordingly.

Accept risk and uncertainty.

Ensure compliance with company policies, specifically patient confidentiality (HIPAA) in all Mainstay Medical practices.

Perform other duties, as required.

Qualifications :

Bachelor's Degree (health economics, life sciences, public health), RN / BSN preferred and a minimum of 5 years related experience, or an advanced degress without experience, or equivalent work experience.

Experience in a medical office, hospital setting, or payer with coding and prior authorization experience or utilization review.

Knowledge of health insurance industry practices and functions.

Experience with Medicare, Medicaid, Tricare, Workers Compensation, and Commercial Insurance.

Superior oral and written communication skills.

Demonstrates excellent organization skills with attention to detail.

Proficient in Microsoft Office, including Microsoft Word, Outlook, Excel, and PowerPoint.

Experience working with platforms such as Salesforce, Availity, eFax systems, and other basic database management programs.

Problem solver and capable to find solutions to challenges or process impediments.

Maintains a caring, empathetic, and patient-centric approach in all interactions.

The salary range for this position is $85,000 to $105,000 / year; however, base pay offered will take into account a range of factors, including job-related knowledge, skills, and experience. The total compensation package includes a range of medical, dental, vision, financial, and other benefits, as well as equity.

Mainstay Medical is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to gender, race, color, religious creed, national origin, age, sexual orientation, gender identity, physical or mental disability, and / or protected veteran status. Mainstay Medical participates in E-Verify.