Payor Specialist - LOA, SCA, Third-Party Payors - Healthcare US - Remote

US
- Remote

The Payor Specialist is responsible for verifying and reverifying insurance coverage and eligibility, submitting and following up on authorization requests, and maintaining follow-up communication with insurance companies.

More specifically, this role verifies patient insurance benefits for specific procedure coverage, updates eligibility information, submits and follows up on authorizations and LOA/SCA requests, and requests network or payment related exceptions.

Core Duties/Responsibilities
:

• Works directly in alignment with Case Management Team to coordinate efforts and prioritize daily activities to meet deadlines.
• Completes insurance benefits verification and reverification to confirm active coverage, benefit details, payor requirements, and applicable patient responsibility.
• Updates eligibility information accurately and timely based on payor verification and reverification findings.
• Submits authorization requests when required and performs timely follow-up through final payor determination.
• Submits Letters of Agreement (LOA) and Single Case Agreements (SCA) when required and performs timely follow-up through rate negotiation, execution, or final payor determination.
• Obtains timely payor determinations regarding authorizations, LOA/SCA requests, network exceptions, and other payment-related needs, and accurately records and conveys determinations to the Payor Specialist Manager/Case Management Team
• Tracks and assures compliance with payor requests for information and communicates payor requests to appropriate Payor Specialist Manager/Case Management Team as applicable.
• Clearly documents and communicates authorization and LOA/SCA outcomes, applicable follow up steps, and payor requirements to the Payor Specialist Manager/Case Management Team
• Communicates out-of-network obstacles and takes proactive steps to elevate network status and optimize in‑network patient benefits to the Payor Specialist Manager/Case Management Team.
• Provides feedback to Payor Specialist Manager/Case Management Team as needed regarding payor guidelines, issues, and determinations discovered during communication with payors.
• Ensures payor and customer satisfaction by utilizing effective communication and interpersonal skills
• Proactively follows up on pending payor correspondence to encourage priority review and expedited turnaround times.
• Interprets payor documentation to ensure accuracy and translates appropriately to the Case Management Team, customer, and patient.
• Follows procedures and instructions to escape or expedite authorization and LOA/SCA review timelines to meet patient and provider treatment scheduling expectations.
• Work collaboratively and cross-functionally between management and programs
• Additional duties as assigned.

Skills / Requirements

• Strong organizational skills, attention to detail, and effective task management while responding productively to changing priorities.
• Remains calm and objective in emotional or stressful situations.
• Learns quickly and applies innovative methods, tools, and technology to the role.
• High level of self-accountability for compliance with policies, procedures, and work requirements.
• Seeks advice when unsure about choosing a course of action.
• Makes solid routine decisions with coaching from others.
• Learns about the key drivers of the organization’s business and uses those learns in the day-to-day work.
• Maintains tenacity and work focus despite obstacles or setbacks and is comfortable dealing with first- time or unusual challenges.
• Adequately supports multiple products and/or programs in various treatment specialties
• Independently manages tasks and follow up responsibilities without direct guidance from management or peers.
• The need to understand insurance contracts and reimbursement methodologies
• Ability to effectively navigate payment negotiations within certain rate parameters.
• Strong expertise in complex insurance framework including but not limited to dual coverage, unique insurance plans, purchase orders, tiered benefits.

Education, Certifications and

Experience:

• Experience with payers and Clinical Guidelines or Medical Policy is preferred.
• Conversant with medical terminology.
• Expertise and knowledge of third‑party payor, Medicare/Medicaid guidelines.
• Computer and database management skills to efficiently and effectively manage proprietary electronic systems.
• Interpersonal and communication skills to effectively deal with a variety of people, including…