Boston Scientific Pre-Authorization Specialist II 

United States, Massachusetts, Marlborough 

672779653

Your responsibilities will include:

• 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
• Answer incoming calls received through the toll-free PASP call center, providing superior customer service and appropriate call/case handling
• Utilize proficient knowledge in Microsoft Office and Salesforce to document case statuses, actions, and outcomes in a timely and accurate manner
• Effectively communicate and build relationships with HCP office and FSO staff regarding all inquiries and handling of cases
• Maintain PASP metrics and standards
• Monitor the inbound email queue, responding and triaging inquiries appropriately
• Monitor the departmental fax queue to coordinate the intake of requests for services and action communication from customers, patients, and payers appropriately
• Report adverse events/product complaints following program Standard Operating Procedures (SOPs)
• Comply with SOPs to maintain data integrity
• 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
• Consistently provide superior quality and service in a high-volume work environment
• Coordinate with lead regarding complicated cases
• Other duties as assigned

Required qualifications:

• High school diploma
• Minimum 2-years’ relevant experience including:
  • Working with various payers including, Medicare, Medicaid, Private Commercial, and VA
  • Reviewing clinical records and extracting keyinformation to support medical necessity
• • Submitting prior authorization requests for medical procedures
  • Understanding and leveraging payer coverage criteria toensure positive outcomes
• Proficient in Microsoft Office
• Excellent written and verbal communication skills
• Ability to work independently with minimal to moderate supervision
• Travel <5%

Preferred qualifications:

• Associate’s degree
• Medical device experience and/or bariatric experience preferred
• Experience utilizing software/systems to perform tasks (e.g., Salesforce, EMR, payer portals, Policy Reporter)
• Experience interpreting procedure denials and drafting appeals

Maximum Salary: $ 67392

Compensation fornon-exempt (hourly), non-sales rolesmay 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 forexempt, non-sales rolesmay 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.

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.

Among other requirements, Boston Scientific maintains specific prohibited substance test requirements for safety-sensitive positions. This role is deemed safety-sensitive and, as such, candidates will be subject to a prohibited substance test as a requirement. The goal of the prohibited substance testing is to increase workplace safety in compliance with the applicable law.