Payor Specialist

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 escalate 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 physicians, hospital leaders, nursing staff, patients, and family members.
• High school diploma with at least five years healthcare experience or Associate's Degree in healthcare-related field with three to four years of experience.

Physical Requirements: 

• As a remote-forward organization, this position operates in a professional virtual office environment and teleworking from the employee’s home address listed in their employment file.
• Prolonged periods of sitting at a desk and working on a computer
• Keyboarding
• Speaking
• Must be able to lift up to 15 pounds at times
• Flexibility of working hours to support activities across EST to PST zones

Our PRO-Spectus Culture Philosophy

At PRO-Spectus we have created a culture that is supportive, dedicated, and teamwork driven.  We celebrate each other’s joys in personal life and professional accomplishments, promoting meaningful relationships and friendships. 

Our employees bring strength of mind and spirit to make the extraordinary happen every day.  With humility and compassion at our core, PRO-Spectus is proud of our relentless focus towards the higher purpose of improving the lives of patients we support.

We recognize it takes a lot of people working together with a common goal to make spectacular happen, and we never forget that at the heart of our company are the people who make it work.

PRO-Spectus is an Equal Opportunity / Affirmative Action employer. All qualified individuals will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, protected veteran status, marital status or other protected status under federal, state or local laws.

At PRO-spectus, we are deeply committed to pay transparency and equity. The hourly range for this position is $30 - 41, based on experience and qualifications, with the final offer reflecting skills and other job-related factors. Beyond competitive pay, we offer a comprehensive and generous benefits package designed to support your well-being and work-life balance. 

Our benefits include robust medical, dental, and vision plans; life insurance and disability coverage; and tax-advantaged savings accounts. We also provide an Employee Assistance Program, home office benefits, and unique perks like an Employee Ownership Program. With paid time off, holidays, bereavement leave, and a 401(k)-retirement plan with employer matching, PRO-spectus prioritizes your financial and personal security. Plus, you may be eligible for a performance-based bonus opportunity. 

Join PRO-spectus, where your career growth, well-being, and contributions truly matter!