Insurance Verification and Appeals Specialist

The Opportunity

The Insurance Verification & Appeals Specialist is responsible for verifying complex benefits, securing pre-authorizations, and managing pre-service Appeals.  This includes disputing insurance denials before the equipment is shipped to the patient. You will verify patient eligibility, obtain prior authorizations, and draft complex clinical upfront appeals. The goal is to minimize estimated out of pocket errors to the patient through meticulous insurance verification. The Insurance Verification and Appeals Specialist reports to the Therapy Access Manager and will not have any direct reports. This is a remote position.

The compensation range for this role is market driven, with a salary range of $68,000 - $90,000. Additionally, we offer a robust benefits package. This offering is aligned with our overall compensation philosophy. 

Applicants must be currently authorized to work in the United States on a full-time basis. Cala will not sponsor applicants for work visas.

A Day in the Life

• Verify specific DME policy inclusions/exclusions, quantity limits, and "same-or-similar" equipment checks via Medicare portals or other payer portals
• Calculate estimated patient responsibility (deductibles vs. coinsurance)
• If a Prior Authorization is denied, you will initiate an immediate Pre-Service Appeal or "Peer-to-Peer" request to overturn the decision.
• Coordinate referral process between the PCP, prescribing HCP in accordance with insurance requirements.
• Identify what is missing in the clinical notes and coordinate with the doctor's office to rectify it.
• Collaborate with the Revenue Cycle Management team to ensure clean claims.
• Support company goals and objectives, policies and procedures; Adhere to Good Manufacturing Practices and FDA regulations
• Document all interactions into the customer relationship management (CRM) system in accordance with Quality Assurance/Regulatory and HIPAA guidelines
• Perform other duties as assigned

Skills and Experience

• Bachelor’s degree is strongly preferred; High school diploma or equivalent required
• Minimum 3 years of experience within the healthcare industry focused on deep understanding of Medicare Part B, Medicare Advantage and Commercial payors guidelines, preauthorization and appeals process.
• Strong organizational skills with attention to detail
• Computer competency including MS Office, Google, Internet, and navigation of customer relationship management (CRM) systems
• Ability to prioritize tasks and manage time effectively in a fast-paced environment
• Excellent written and verbal communication skills