Job Description

What we are looking for

Optime Care is seeking a Prior Authorization and Appeals Specialist. We are looking for someone who is passionate about helping people get the specialized therapies they need. This critical role manages the process of receiving, researching, and resolving Prior Authorizations and Appeals issues with health insurance companies, including any escalated step of the appeals process.

What the position will be doing

• Ensure prior authorizations and appeals cases follow current CMS guidelines and timeliness criteria which includes communicating directly with providers and insurance companies.
• Prepare case files for Independent Review Entities or other levels of the Appeals process.
• Document all activities of the Prior Authorizations and Appeals process.
• Compose technical denial arguments for reconsideration.
• Overcome objections that prevent payment of claims and gain commitment for payment through concise and effective appeal argument.
• Identify problem payors, processes, and trends and escalating where appropriate.
• Utilize documentation standards that support a strong historical record of actions taken
• Write and complete final editing of letters of determination sent out for appeals.
• Produce and manage inbound and outbound correspondence in a manner that meets required timeframes.
• Prepare case files for Independent Review Entities or other levels of the Appeals process.
• Assist with internal and external audit processes.
• Proactively identifies areas of improvement for self and the department.
• Work with assigned clients to assess trends around payer responses.
• Participate in the development and completion of individual and departmental initiatives.
• Other duties as needed or assigned.

Necessary Skills, Education & Abilities

• High school diploma, or equivalent, required.
• 2 or more years of experience with medical/pharmacy insurance verification including benefit investigation.
• Current Missouri BOP Pharmacy Technician license, or Nurse license in good standing.

• Knowledge of prior authorizations and claim appeals.
• Medical terminology required.
• Knowledge of medical/pharmacy insurance benefit language; ie. EOBs, deductibles, Out of pocket, coinsurance, co-pays, etc.
• Ability to work independently, with limited supervision.
• Effectively meet established productivity, schedule adherence, and quality standards
• Ability to define CMS 1500s, provider numbers, CPT, HCPC’s, ICD9, NCPDP and NDC codes/numbers
• Ability to utilize critical thinking skills to identify issues and required actions within an appeal
• Computer literate and proficient with Microsoft Office
• Ability to participate in and facilitate group meetings
• Ability to thrive in a fast-paced environment with constantly changing and competing priorities.
• Excellent analytical skills and the ability to provide solutions to complex problems.
• Ability to be highly transparent, ethical, and driven. Relentless attention to detail, and the ability to be a creative self-starter and team player.
• Excellent written and verbal communication skills, and interpersonal skills required.
• Willingness to work a flexible schedule

About us

Optime Care is a Specialty Pharmacy dedicated to providing services to smaller patient communities. We focus on securing insurance coverage, coordinating care, and complying with therapy regimens are only a few examples. Our mission is to minimize the daily impact of living with unique disorders. After just one call, our experts begin to address everything from medication delivery and insurance reimbursement to compliance and education. Every patient receives a proactive service experience tailored to their specific needs.

What sets us apart

· Our focus on people- our customers, partners, and coworkers

· A company culture that embraces going beyond expectations in everything we do

· A leader in providing specialty pharmaceuticals to individuals with unique conditions

· An opportunity to learn from some of the best in the business

· A diverse and inclusive culture that embraces innovation

Optime Care provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

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