Authorization & Appeals Specialist - Cardio Partners - Remote

Summary

The Authorization & Appeals Specialist is responsible for receiving and processing DME referrals, verifying patient eligibility, and coordinating equipment delivery. It involves detailed data entry, insurance interaction, and communication with healthcare providers and patients. The role requires strong administrative, communication, and insurance knowledge to ensure accurate and efficient service delivery. Organizational Impact The Authorization & Appeals Specialist plays a critical part in ensuring timely and accurate processing of Durable Medical Equipment (DME) referrals, which directly supports patient care continuity and satisfaction. By managing insurance verifications, authorizations, and appeals, the position helps reduce claim denials and improves reimbursement efficiency. The role also enhances operational coordination across departments, contributing to streamlined workflows and regulatory compliance. Essential Duties And Responsibilities

• Review clinical denials including but not limited to referral, pre-authorization, medical necessity, non-covered services
• Draft and submit authorization request to the Health Plan/Medical Director based on the review of clinical documentation with Medicare, Medicaid, and third-party guidelines
• Performs data entry, answers telephone, and directs calls to the appropriate staff and performs basic clerical duties and any other duties as assigned
• Serves as first line of contact for referral client care calls from physician’s offices, and others
• Maintains referrals and receives and tracks information regarding changes in client status
• Verifies patient eligibility
• Coordinate Instructor call backs to patients with questions
• Must ensure appropriate patient documentation is received prior to delivering medical equipment; securing a valid prescription, physician written order and physician medical notes
• Arrange delivery of medical equipment to patient’s home
• Maintain inventory tracking of medical equipment
• Research policies regarding AED Insurance Coverage
• Periodically reverifies Medicaid State Allowable
• Create, organize, and file patient charts
• Conduct and record cash sales when working through insurance is not feasible
• Supports office operations
• Works closely with Nursing coordinator and Instructors from the referring doctor’s office
• Additional job duties as assigned

Skills/Experience Required

• Education: High School Diploma or equivalent required
• Minimum of 2-years’ experience working with insurance companies required
• Knowledge and application of managing and appealing denials
• Working knowledge of Medicare, Medicaid, HMO’s, and PPO’s is essential as well as knowledge of HIPAA regulations
• Must be familiar with Insurance companies and the duties associated with patient intake information; verification, preauthorization; benefit identification to include coinsurance and deductibles; billing and collection
• Must have experience in medical insurance terminology, CPT, ICD coding structures, and billing forms 1500
• Knowledge of home medical equipment is a plus
• Self-directed and highly motivated with a “can do” attitude
• Superior interpersonal abilities; ability to get along with diverse personalities, tactful, flexible
• Good communication skills; well-developed administrative skills
• Writing and verbal communication skills are required in English
• Must possess and show development of outstanding communication, leadership, and situational awareness skills
• Ability to work well under pressure in a fast-paced environment with frequently changing priorities, deadlines, and workloads. Strong time management skills
• Ability to be objective in discussions and decisions making

Physical Requirements

• Sit, walk, stand, use hands to manipulate, handle, feel, and control items or equipment
• Reach with hands and arms
• Talk and hear
• See and be able to read, write, and interpret text
• Employee may use computer, phone, copier and other office equipment in the course of a day
• Occasionally lift and move objects weighing up to 10 pounds
• Employee may be required to travel for business purposes
• When working remotely, ability to secure confidential information
• When working remotely, perform all duties in a professional environment free of noise or anything that would create a negative customer experience

Work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential function of this job. Reasonable accommodations m Apply To This Job