Specialist

Job Description

Responsibilities

What You’ll Do

Comprehensive Benefit Verification

• Conduct thorough phone and portal-based benefit verifications. Once a patient is confirmed as clinically appropriate, you own the VOB from start to finish.
• Determine the details automated checks miss — medical vs. pharmacy routing, code-level coverage, exact deductible/OOP status, coinsurance, coordination of benefits, and prior authorization requirements.
• Translate VOB findings into a clear, actionable summary for the practice. No jargon, no ambiguity — the practice should be able to act on your output without follow-up questions.

2. Prior Authorization Management

• Own the full PA lifecycle for Spravato, TMS, and other treatments: initial submission through approval, with proactive re-authorization so there are never gaps in care.
• Select the right submission channel based on payer and treatment type (CoverMyMeds, Availity, payer-specific portals, fax/phone where needed).
• Monitor status actively. Follow up before things get stuck. On denial, identify the cause and coordinate appeals or peer-to-peer requests with the practice.
• Understand what each payer requires and confirm clinical documentation supports medical necessity before submission.

3. Payer Pushback & Problem Ownership

• When a VOB or PA response doesn’t add up, you investigate — you don’t just document and move on.
• Call payers back with targeted questions. Cross-reference portal data with phone results. Identify whether the issue is a data error, a policy misapplication, or a legitimate coverage limitation.
• Escalate with context: when you bring an issue to the team, you’ve already done the legwork.

4. Provider Communication

• Write clear, concise, professional messages to practices. Every benefit summary, PA update, and denial communication should be something a provider can act on without a follow-up call.
• Be the calm, organized voice when a payer outcome is confusing or frustrating. Your follow-through and communication quality are what make a practice feel they’re in the best possible hands.

5. Self-Management & Technology

• Manage your own queue. Flag expiring authorizations before they expire. Raise blockers promptly and specifically — don’t sit on problems.
• Pick up new platforms quickly and independently. All internal tools are proprietary — you won’t have used them before, and that’s expected. What we need is the confidence and resourcefulness to learn them.

Required Experience

• 2+ years of hands-on experience in benefit verification and prior authorization (not just claims or cash posting)
• Strong command of VOB vocabulary and mechanics: deductibles, coinsurance, OOP maximums, medical vs. pharmacy routing, PBMs, coordination of benefits
• End-to-end PA lifecycle experience: submission, status monitoring, denial management, appeals
• Experience with major payer portals (Availity, Navinet, Optum, or payer-specific) and pharmacy PA platforms (CoverMyMeds or comparable)
• Clear, professional written English — you can write a provider-facing message that needs zero edits
• Demonstrated ability to learn new technology independently
• US-based, remote-eligible

Nice to Haves

• Behavioral health, psychiatry, or mental health billing background
• Spravato and/or TMS BV/PA experience
• Experience communicating directly with clinicians or practice administrators
• Familiarity with AI tools (Claude, Gemini) in a daily workflow
• Pylon or comparable ticketing platform experience
• Candid Health experience
• A/R Follow-Up experience

Are you interested in this position?
Apply by clicking on the “Apply Now” button below!
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