PRIA Healthcare Management

The Patient Access Specialist - Executive Lead is a senior-level position, within the patient access team, responsible for overseeing the authorization process and leading a team of authorization specialists. This role involves strategic planning, process improvement, and ensuring compliance with healthcare regulations. This role will promote collaboration with client representatives and internal PRIA teams through the development of informative reporting systems, team meetings, and trainings as needed.Additionally the Patient Access Specialist- Executive Lead should maintain a positive, collaborative, and high-performing work environment where employees are motivated to contribute to the success of the organization.

Key Responsibilities:

• Lead and manage a team of patient access specialists to achieve departmental goals.
  • Monitor and analyze data within the salesforce platform to identify areas for improvement and efficiency.
    • Responsible for teams KPIs
  • Train and mentor new patient access specialists.
  • Audit a select number of cases per program as directed by the Director, Patient Access
• Work closely with other Executive Leads and the Director, Patient Access to improve/enhance operations best practices
• Maintain open communication with each program assigned Strategic Account Manager and work in conjunction with them on, weekly program reviews, calls, frequent questions or concerns regarding the program
  • Escalate issues to the program Strategic Account Managers as needed
• Manage a case load for an assigned program
  • Data enty and review of new patient cases into system database
  • Communicate with physician's office and their staff regularly
  • Maintain accurate and up-to-date records within the salesforce platform to ensure accurate reporting to clients.
  • Complete full patient access process as outlined by program SOP including but not limited to:
    • Analyze and interpret patient clinical data, clinical notes and files to determine medical necessity criteria is met specific to each payer policy
    • Review multiple insurance policies to define medical necessity criteria to support medical device/procedure(s)
    • Benefits verification and payer discovery
    • Prior Authoriation/ Pre- service review submissions, pre and post service appeal submissions
    • Ensure all documents developed to support an appeal are accurate, consistent, up to date, and in compliance with applicable Standard Operating Procedures, guidelines, and regulations.
  • Ensure compliance with all regulatory and company policies.

KPIs

• KPI's based on the following factors
  • Programs under management
    • Number, complexity, and volume
  • Number of Patient Accesss Specialist under management
  • Audit needs per program
• Established based on the program complexity and align with program success
  • Once KPIs are established they are measured daily, weekly and monthly

Qualifications:

• College degree preferredbut will substitute forapplicable work experience
• Minimum of 5 years of experience in healthcare authorization, with at least 2 years in a supervisory role.
• In-depth knowledge of insurance processes, medical terminology, and healthcare regulations.
• Strong leadership, analytical, and problem-solving skills.
• Excellent communication and interpersonal skills.