Position Overview

MCRA, and IQVIA Business is currently seeking a Director, Patient Access Program (PAP) Operations to lead our Patient Access Programs and Team. This role requires leadership, program management and day to day administrative and operational oversight of the Patient Access Team and all associated activity with the team. Under the general direction of the VP, RHEMA, the Director, Patient Access Program Operations will lead and provide oversight to the Patient Access Team who are responsible for collaborating with providers and patients, conducting benefit verifications, prior authorization submissions and follow ups, initiating and following up on claim appeals (all levels) and also answering general coding questions that come through the support line for new and novel technologies using a CAT III CPT code or an unlisted CAT I CPT code.

The Director, Patient Access Program Operations is also responsible for designing and implementing patient access programs, following an established framework, in addition to all ongoing program activities, including client escalations, monthly metric calls and program reporting and data. This role asks that you contribute to the development of administrative functions, including workflows, policies and procedures, staff training, and documentation.

This is a leadership position in a fast-paced, results driven environment. Through MCRA supported training and continuing education, reimbursement personnel are required to become experts in the disease states of spine, orthopedics, biologics, cardiovascular and other areas affected by specific clinical/surgical interventions, treatment alternatives and the technologies themselves.

Responsibilities

• Provide proactive leadership, administrative and operational support to MCRA’s Patient Access Program (PAP) team and clients.
• Ensures all incoming cases are logged in system and assigned to the appropriate Case Manager.
• Confirms all assigned cases are worked within the established service level agreement guideline.
• Communicates with PAP clients, providers, and insurers to mitigate case barriers for escalated cases.
• Updates internal SOPs and communicates these changes with team and clients as needed.
• Reviews template letter composition for quality and correctness prior to submission to health plan and or provider.
• Analyze insurer correspondence, clinical notes, insurance medical policies and medical device guidelines to assist case managers with case strategy formation, as needed.
• Work with Finance to ensure that all billable time is accurately allocated to PAP clients and assist with invoicing matters, as needed.
• Completes case auditing to ensure quality of data collection and case summaries.
• Develops direct reports and seeks process improvement opportunities to improve and optimize workflows.
• Meets with PAP clients monthly, to review program metrics and performance. In addition to supplying monthly reports package to all PAP clients.
• Assist with new program design, development, and implementation.
• Attends Business Development calls for prospective PAP clients.
• Partners with other RHEMA teams for mixed cross-selling opportunities.
• Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
• Ability to complete special projects or other duties as assigned.
• Adheres to all HIPAA and PHI compliance policies.

Required Qualifications

• Bachelor’s Degree in Business, Healthcare Administration, Finance or and Associates Degree and a Coding certification (such as CPC or CPC-A), with 8-10+ years’ experience working in a leadership capacity.
• 5-8 years of medical billing/coding, including benefit verification, prior authorization, and claim appeals.
• Familiarity with medical terminology and coding, i.e., CPT, HCPCS, ICD-10.
• Understanding of CMS -1500 claim forms, prior authorization forms and appeals forms for claims adjudication.
• Deep payer research skills using tools such as Policy Reporter, etc.
• Working knowledge of federal and commercial insurance products, procedures, claims process and medical policies.
• Professional demeanor and communications skills both oral and written
• 5+ years of managing a team, delegating work, and checking work quality. Including experience with developing people, processes and administering corrective action and performance improvement plans.
• Proficiency with MS Office Suite, including Word, PowerPoint, Excel, Word, and Outlook
• Self-directed individual who demonstrates initiative and can manage assignments with little oversight. Demonstrates effective time management skills and the ability to manage multiple priorities and assignments.
• Results oriented and metric driven.
• Moderate understanding of HIPAA and PHI handling practices.
• Ability to work effectively leading a team in office and remotely.

Preferred Qualifications

• Understanding of how to use Payer portals such as, NaviNet, Avality, CMS (CEDI), UHC, etc.
• Knowledge of medical device, biopharmaceutical billing.
• Experience working administratively within a health care setting is highly desirable, preferably for a health insurer, physician practice, ambulatory care center and/or hospital facility.
• Ability to work with broad spectrum of diagnoses coding.
• CPC Certification not required but highly preferred.