Patient Access Specialist – Medical Necessity Investigation

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  "language": "en",
  "location": {
    "raw": "Farmington, Connecticut, United States",
    "city": "Farmington",
    "region": "CT",
    "country": "United States",
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    "id": "123",
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    "atsLocation": {
      "city": "Farmington",
      "state": "Connecticut",
      "country": "United States",
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    "departmentId": "18749",
    "locationType": "1",
    "jobOpeningName": "Patient Access Specialist – Medical Necessity Investigation",
    "departmentLabel": "Patient Access Specialists",
    "employmentStatusLabel": "Full-Time"
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    "datePosted": "2026-05-20",
    "atsLocation": {
      "city": "Farmington",
      "state": "Connecticut",
      "country": "United States",
      "countryId": "1"
    },
    "description": "<p><span style=\"font-weight: bold\"><span><span>Position Overview:</span></span></span><span> <br></span><span><span>The Patient Access Specialist is a mid-level role within the Patient Access </span><span>team and</span><span> </span><span>is responsible for</span><span> supporting our client’s reimbursement needs to </span><span>facilitate</span><span> patient access to their technologies and procedures.  This position will support a variety of key economic stakeholders, including client company representatives and their customers such as physicians, billing and coding personnel, hospitals, and ambulatory surgical centers. This role will serve as a subject matter expert in patient access services, including </span><span>benefits</span><span> verification, prior authorization, pre-service appeals, and post-service claims appeals.</span></span><span> </span></p>\n<p><span> </span></p>\n<p><span><span style=\"font-weight: bold\">A core responsibility of this position will involve conducting detailed medical necessity investigations by thoroughly reviewing patient clinical documentation and cross-referencing it against payer-specific medical policies, coverage guidelines, and authorization criteria to determine</span><span><span style=\"font-weight: bold\"> eligibility and support coverage approval.</span> The role requires strong analytical and critical thinking skills to interpret clinical information, </span><span>identify</span><span> gaps in documentation, and develop strategic recommendations to support reimbursement outcomes.</span></span><span> </span></p>\n<p><span> </span></p>\n<p><span><span>This position will also </span><span>be responsible for</span><span> navigating complex payer requirements, researching policy nuances across commercial and government payers, and collaborating with providers and internal stakeholders to obtain and </span><span>validate</span><span> the clinical information necessary to support authorization and appeal submissions.</span></span><span> </span></p>\n<p><span> </span></p>\n<p><span> <br></span><span style=\"font-weight: bold\"><span><span>Key Responsibilities:</span></span></span><span> </span></p>\n<ul>\n<li><span><span>Participation on weekly program calls as needed</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Perform detailed medical necessity investigations by cross-referencing patient clinical documentation, physician notes, and supporting records against payer-specific coverage policies and authorization criteria to </span><span>determine</span><span> eligibility for medical device and procedural approval.</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Train and mentor new patient access specialists.</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Audit a select number of cases per program as </span><span>directed by the Director</span><span>/Manager</span><span>, Patient</span><span> Access</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Manage a case load for an assigned program</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Data </span><span>entry</span><span> and review of new patient cases into system database</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Serve as a primary point of contact for providers and patients seeking insurance coverage </span><span>assistance</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Communicate with physician’s office and their staff regularly</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Maintain </span><span>accurate</span><span> and up-to-date records </span><span>within the salesforce platform to ensure </span><span>accurate</span><span> reporting to clients</span><span>.</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Complete full patient access process as outlined by program SOP including but not limited to:</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Analyze and interpret patient clinical data, clinical </span><span>notes</span><span> and files to </span><span>determine</span><span> medical necessity criteria is met specific to each payer policy</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Review multiple insurance policies to define medical necessity criteria to support medical device/procedure(s)</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Conduct case-related research</span></span><br><span><span>(e.g., payer coverage policies, self-funded plans, </span><span>state</span><span> and federal regulations).</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Benefits verification</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Prior </span><span>Authorization</span><span>/ Pre- service review submissions, pre and post service appeal submissions </span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Ensure all documents developed to support an appeal are </span><span>accurate</span><span>, consistent, </span><span>up to date, </span><span>and in compliance with applicable Standard Operating Procedures, guidelines, and regulations.</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Maintain strong professionalism, ethics, and compliance with all applicable laws and policies</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Ensure compliance with all regulatory and company policies.</span></span><span> </span></li>\n</ul>\n<p><span style=\"font-weight: bold\"><span><span>KPIs</span></span></span><span> </span></p>\n<ul>\n<li><span><span>Established based on the program complexity and align with program success </span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Once KPIs are </span><span>established</span><span> they are measured daily, </span><span>weekly</span><span> and monthly </span></span><span> </span></li>\n</ul>\n<p><span> <br></span><span style=\"font-weight: bold\"><span><span>Qualifications:</span></span></span><span> </span></p>\n<ul>\n<li><span><span>College degree preferred but will substitute for applicable work experience</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Minimum of </span><span>4</span><span>-</span><span>5 </span><span>years </span><span>experience</span><span> in a healthcare setting, preferably in authorization or billing.</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span> In-depth knowledge of insurance processes, medical terminology, and healthcare regulations.</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Preferred e</span><span>xperience</span><span> with</span><span> supporting mental health treatment programs, specifically those related to Major Depressive Disorder (MDD)</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Knowledge of Medicaid, Medicare, and commercial payer requirements, including prior authorization and appeals processes.</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Strong problem-solving skills.</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Ability to remain patient, empathetic, and composed throughout long, time-intensive interactions with individuals experiencing mental health challenges</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Strong analytical, and problem-solving skills.</span></span><span> </span></li>\n</ul>\n<ul>\n<li><span><span>Excellent communication and interpersonal skills.</span></span><span> </span></li>\n</ul>\n<p><span> </span></p>\n<p><span> </span></p>",
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    "jobOpeningName": "Patient Access Specialist – Medical Necessity Investigation",
    "departmentLabel": "Patient Access Specialists",
    "jobOpeningStatus": "Open",
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    "jobOpeningShareUrl": "https://pria.bamboohr.com/careers/123",
    "employmentStatusLabel": "Full-Time"
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