Reimbursement Clinical Case Manager

At MIMEDX, our purpose starts with helping patients heal. We are driven by discovering and developing regenerative biologics utilizing human placental tissue to provide breakthrough therapies addressing the unmet medical needs for patients across multiple areas of healthcare. Possessing a strong portfolio of industry leading advanced wound care products combined with a promising clinical pipeline, we are committed to making a transformative impact on the lives of patients we serve globally.

POSITION SUMMARY:

Research and answer questions as it relates to payer authorizations and medical policy requirements. Work with health plan personnel and physicians to obtain required clinical information, and educate them on successful and cost effective medical management options. Adhere to all applicable policies, procedures, processes and systems in order to optimize the maximum reimbursement levels.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Work daily pending case reports to ensure prompt processing and closure of payer authorization requests
• Work with internal medical team on large wound cases to confirm clinical appropriateness of product being requested
• Identify and obtain needed information from health plan, physician, and/or reimbursement team as needed to ensure clinical criteria provided meets medical criteria requirements of payer
• Interact with health plan case managers and medical directors, and physicians; educate and influence their decisions related to medical management recommendations for approval of reimbursement
• Receive and handle calls from physician's office, health plan, and sales team related to medical documentation and clinical assessments; research answers to ensure accurate information is communicated
• Prepare daily status reports of pending cases that is used by management to calculate authorization approval percentages by payer
• Update system (SalesForce) with new/different information for existing payers as it relates to their processes
• Build and maintain strong relationships with physician offices and sales team
• Act as back-up to supervisor or manager, as needed
• Follow HIPAA policies and procedures to ensure compliance

EDUCATION/EXPERIENCE:

• BS/BA in related discipline
• 2-5 years of experience in related field with 1-3 years of progressive responsible positions, or verifiable ability

OR

• MS/MA and 1-3 years of experience in related field. Certification is required in some areas
• Prefer RN/LPN
• Basic knowledge of medical coding including ICD10, CPT and HCPCS codes; AAPC certification a plus
• Comprehensive understanding of Medicare, Commercial and Medicaid health plans
• Comprehensive understanding of medical management and health insurance concepts
• Experience in insurance verification, appeals negotiations and processing, billing/claims processing, data processing, and software operations in the health care industry

SKILLS/COMPETENCIES:

• Excellent oral, written, and interpersonal communication skills
• Ability to interact with all levels of management, both internal and external, third party payers, and customers; with a focus on customer service
• Proficient in Microsoft Office (Excel, Word, etc.)
• Organized, flexible, and able to multi-task while maintaining a high level of efficiency and attention to detail
• Strong analytical skills, clinical interests, strategic and technical analysis and problem solving skills
• Ability to make quick, sound decisions based on policy, past practices, and experience
• Ability to influence others to achieve desired results, using tenacity and diplomacy

WORK ENVIRONMENT:

The work is typically performed in a normal office environment.

Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to, or requirements for, this job at any time.