Lead Pre Authorization Specialist

Additional Location(s):  N/A

Diversity - Innovation - Caring - Global Collaboration - Winning Spirit - High Performance

At Boston Scientific, we’ll give you the opportunity to harness all that’s within you by working in teams of diverse and high-performing employees, tackling some of the most important health industry challenges. With access to the latest tools, information and training, we’ll help you in advancing your skills and career. Here, you’ll be supported in progressing – whatever your ambitions.       

About the role:

The Lead Pre Authorization Specialist is the team lead of the Patient Access Support Program (PASP), performing expert benefit verification, prior authorization, and appeal functions. This position will work closely with PASP team members, internal and external customers, and payers to secure insurance approval for endobariatric procedures using Boston Scientific devices. This role is a subject matter expert, focusing on identifying and overcoming challenges in the patient access program and reimbursement landscape.

Visa Sponsorship

Boston Scientific will not offer sponsorship or take over sponsorship of an employment visa for this position.

Your responsibilities will include:

• Act as a subject matter expert and operational lead, always exercising sound judgment and effective communication, and providing day-to-day operational assistance to Pre-Authorization Specialists as it relates to insurance coverage policies, prior authorization and appeal processes, PASP program workflow, and best practices
• Utilizing billing and coding expertise, perform efficient analysis of denied claims, identifying reason(s) for denial and potential for successful resubmission, redetermination, or appeal through current coding and regulatory guidelines, payer guidelines, and clinical criteria
• Monitor payer trends as it relates to approvals/denials and communicate trends to the manager and team
• Verify medical insurance benefits and coverage, including the ability to obtain and process payer forms
• Submit prior authorization/pre-determination requests, and internal and external appeals to health plans to assist the team in achieving identified goals and objectives
• Apply pressure on health plans that refuse to review based on negative or absent coverage policy for Endobariatric procedures (i.e., Endoscopic Sleeve Gastroplasty, Transoral Outlet Reduction Endoscopy)
• Follow up on prior authorization and appeal requests to health plans to ensure receipt and proper review for medical necessity
• Draft letters for internal and external appeal
• Monitor and re-engage payer until final determination is made, ensuring each available level of appeal is used and all appeal rights are exhausted
• Confirm accuracy of authorization approval details, ensuring all codes are captured and the place of service, rendering physician, and surgery date are accurate
• Utilize proficient knowledge in Microsoft Office and Salesforce to document case statuses, actions, and outcomes in a timely and accurate manner
• Mediate high priority and escalated calls with customers in providing front line support for immediate resolution and assistance
• Pro-actively communicate, educate/train, implement, drive and support workflow enhancements and efficiencies
• Assist manager with the development of training material
• Assist manager with quality assurance review, auditing, call monitoring, and coaching of staff
• Develop and monitor reports on PASP metrics and KPIs; lead projects as directed
• Answer incoming calls received through the toll-free PASP call center, providing superior customer service and appropriate call/case handling
• Report adverse events/product complaints following program Standard Operating Procedures (SOPs)
• Comply with SOPs to maintain data integrity
• Monitor the inbound email queue, responding and triaging inquiries, ensuring all correspondence is handled timely and appropriately
• Monitor the departmental fax queue to coordinate the intake of requests for services and action communication from customers, patients, and payers appropriately, ensuring all correspondence is handled timely and appropriately
• Maintain HIPAA compliance and patient confidentiality
• Engage and commit to the organization's culture of continuous improvement by actively participating, supporting, and promoting BSC Mission and Values
• Other duties as assigned

Required qualifications:

• High School Diploma
• 6+ years of relevant experience including:
  • Two of those years must include experience in denied claims mitigation with both Government and Commercial insurance plans
  • Working with various payers including, Medicare, Medicaid, Private Commercial, and VA
  • Submitting prior authorization requests for medical procedures
  • Interpreting procedure denials and drafting appeals
  • Understanding and leveraging payer coverage criteria to ensure positive outcomes
  • Utilizing software/systems to perform tasks (e.g., Microsoft Office, Salesforce, EMR, payer portals, Policy Reporter)
• In-depth knowledge of reimbursement procedures, revenue cycle processes, health insurance claims, billing and coding, and related State, Federal, and Medicare regulations
• Ability to analyze complex data sets and perform extensive audits to identify problems, trends, and potential risk/compliance issues
• Strong analytic, time management, and organization skills, with high attention to detail
• Ability to work independently with minimal supervision
• Travel <5%

Preferred qualifications:

• Associate’s degree
• Medical device experience and/or bariatric experience preferred
• Demonstrated ability to successfully lead an operational team and training staff on processes, procedures, and best practices

Requisition ID: 599034

Minimum Hourly Rate: $23.45 

Maximum Hourly Rate: $39.85 

The anticipated compensation listed above and the value of core and optional employee benefits offered by Boston Scientific (BSC) – see www.bscbenefitsconnect.com--will vary based on actual location of the position and other pertinent factors considered in determining actual compensation for the role. Compensation will be commensurate with demonstrable level of experience and training, pertinent education including licensure and certifications, among other relevant business or organizational needs. At BSC, it is not typical for an individual to be hired near the bottom or top of the anticipated salary range listed above.

Compensation for non-exempt (hourly), non-sales roles may also include variable compensation from time to time (e.g., any overtime and shift differential) and annual bonus target (subject to plan eligibility and other requirements).

Compensation for exempt, non-sales roles may also include variable compensation, i.e., annual bonus target and long-term incentives (subject to plan eligibility and other requirements).

For MA positions: It is unlawful to require or administer a lie detector test for employment. Violators are subject to criminal penalties and civil liability.

As a leader in medical science for more than 40 years, we are committed to solving the challenges that matter most – united by a deep caring for human life. Our mission to advance science for life is about transforming lives through innovative medical solutions that improve patient lives, create value for our customers, and support our employees and the communities in which we operate. Now more than ever, we have a responsibility to apply those values to everything we do – as a global business and as a global corporate citizen.

So, choosing a career with Boston Scientific (NYSE: BSX) isn’t just business, it’s personal. And if you’re a natural problem-solver with the imagination, determination, and spirit to make a meaningful difference to people worldwide, we encourage you to apply and look forward to connecting with you!

At Boston Scientific, we recognize that nurturing a diverse and inclusive workplace helps us be more innovative and it is important in our work of advancing science for life and improving patient health. That is why we stand for inclusion, equality, and opportunity for all. By embracing the richness of our unique backgrounds and perspectives, we create a better, more rewarding place for our employees to work and reflect the patients, customers, and communities we serve. 

Boston Scientific Corporation has been and will continue to be an equal opportunity employer. To ensure full implementation of its equal employment policy, the Company will continue to take steps to assure that recruitment, hiring, assignment, promotion, compensation, and all other personnel decisions are made and administered without regard to race, religion, color, national origin, citizenship, sex, sexual orientation, gender identify, gender expression, veteran status, age, mental or physical disability, genetic information or any other protected class.

Please be advised that certain US based positions, including without limitation field sales and service positions that call on hospitals and/or health care centers, require acceptable proof of COVID-19 vaccination status.  Candidates will be notified during the interview and selection process if the role(s) for which they have applied require proof of vaccination as a condition of employment.  Boston Scientific continues to evaluate its policies and protocols regarding the COVID-19 vaccine and will comply with all applicable state and federal law and healthcare credentialing requirements.   As employees of the Company, you will be expected to meet the ongoing requirements for your roles, including any new requirements, should the Company’s policies or protocols change with regard to COVID-19 vaccination.