Test Job iCims Career Site II (Remote) - Tactile Medical

Overview:

The Case Management Specialist is responsible for reviewing clinical documentation and drafting statements of medical necessity to address requirements of health insurance (payer) medical policies.  This role also identifies payer challenges when they arise, proposes internal payer requirement changes when necessary, and responds to payer requests for additional information in the prior authorization, appeal and claim process.

 

This position acts as an advocate for the patient during the prior authorization appeal process by coordinating with the patient and/or clinician for additional information, communicating details of the denial and drafting professional, concise and persuasive letters on their behalf in response to denials of coverage.

Responsibilities:

• Develop well-written commercial payer appeal packages that support medical necessity and address payer objections using clinical information, payer medical policies and studies/research available
• Effectively and professionally communicate pertinent information to clinicians, payers, patients and field representatives
• Prepare individualized statements of medical necessity
• Review clinician documentation for specific criteria to satisfy payer medical policy requirements
• Review clinical merit of case to determine if appeal is an appropriate option
• Educate payer clinical review staff and/or medical directors about lymphedema and the treatment provided by company products
• Collaborate with colleagues, patients, clinicians, payers and field representatives to overcome individual order denials and understand payer coverage criteria 
• Identify positive and negative payer trends and escalate to management proactively
• Develop and foster a strong and effective relationship with key payer personnel to allow Tactile Medical the ability to demonstrate the cost and medical benefits of company products for treatment of lymphedema and wound care
• Meet or exceed department productivity and quality measures
• Be a team player and proactively assist other team members
• Be a champion for continuous process improvement. Ask questions and continually look for ways to make processes better, faster or more efficient
• Contribute to regular 1:1, small and large group team meetings
• Maintain compliance with all appropriate regulatory requirements including HIPAA
• Other duties as assigned

Qualifications:

Education & Experience
Required:

• Bachelor’s degree or equivalent work experience
• Previous experience in persuasive writing and case review assessing coverage criteria,
• 2-4 years’ experience in medical device industry, payer or related field

Preferred:

• Clinical background

Knowledge & Skills

• Strong proficiency with Microsoft Office Suite, including Word, Outlook and Teams
• Understanding of payer methodologies (coding, coverage, prior authorizations, clinical criteria and payments)
• Self-starter with ability to work independently and operate as a strong team player with a high degree of flexibility
• Exceptional written communication skills with emphasis on persuasion and clinical knowledge
• Strong critical and strategic thinking skills
• Knowledge of medical terminology Ability to communicate clearly and effectively with all types of employees, patients and clinical staff
• Capable of aligning understanding of payers with Tactile’s organizational goals and objectives
• Thrive in a fast-paced, continuously changing environment by prioritizing and balancing multiple deadline driven priorities

Below is the starting salary range for this position, although offers may differ based on the candidate's location, job-specific knowledge, skills and experience.:$15 - $20