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Reimbursement Specialist (Remote) at Genomic Health
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Reimbursement Specialist (Remote)

Apply Share Job ID 1224 Category Commercial Operations Job Location Redwood City, California Posted Date 11/13/2018

Overview:

The Genomic/Oncotype Reimbursement Specialist will work directly with patients, prescribing physicians, sales force and payers to educate on the appeals process and support efforts to overturn medical necessity or other claim denials to gain maximum, in network coverage of GHI Products. The Genomic/Oncotype Reimbursement Specialist will be tasked with developing an appeals strategy for Genomic Health which will focus on US based private insurances. The strategy will be defined to match each respective product and align with their current state of need. Must have the ability to manage a large case load, interpret medical records and physician notes and compose clearly articulated letters of appeal. The Genomic/Oncotype Reimbursement Specialist will work closely with Medical Affairs as they develop personalized appeals from patient interviews, physician interviews and medical records findings.

Essential Duties and Responsibilities:
· Lead the development of an appeal strategy which will focus on initiatives to aggressively pursue approvals, overturn denials, seek alternative methods of coverage, and establish precedence with key payers.
· Leverage clinical expertise related to oncology care; arrange and prepare physicians for peer review; write draft letters of medical necessity for prescribing physician
· Complete appeal reviews to ensure appropriate application of clinical criteria/guidelines and medical policy
· Use historical approvals with same/similar payers to overturn claim denials
· Use third party documents, such as FDA approval letters, Medicare coverage determinations, technology assessments (such as Hayes or Evidence Street) and other commercial health plan medical policies, to demonstrate breadth of coverage and to indicate higher evidentiary ranking.
· Pursue legal action against payer when necessary and with input from Managed Care, Legal and others as appropriate
· Engage and educate patient advocacy groups, patients, physicians and office staff around the billing and reimbursement process (i.e. educating on prior authorization, appeals process, etc.)
· Implement any other appropriate means to gain a favorable claim determination
· Lead the development of key performance metrics for appeals program that demonstrate program success and cost effectiveness
· Identify trends and work with members of Managed Care to adjust internal policies (such as billing and reimbursement or ordering policies) and appeal strategy and/or appeal letters
· Responsible for tracking all cases in appeal for performance measurement and outcomes purposes
· Keep intake staff apprised of payer success stories and coach them how to overcome payer objections to coverage.
· Assist in the development of standard template letters of appeal to be used in first level appeals
· Ensure compliance with HIPAA regulations, to include confidentiality, as required.
· Performs other duties as assigned by Management.
Supervisory Responsibilities: None.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job.

Educations and/or Experience:
· Bachelor's degree in nursing with a Registered Nurse designation preferred but not required.
· 5+ years' experience as a hospital or payer-based case manager or discharge planner.
· Excellent clinical skills related to oncology case management.
· Persuasive negotiation and time management skills along with a strong knowledge of all payer types, to include Medicare, Medicaid, and third party commercial insurance companies.
· Proficiency in MS Office Suite.

Language Skills: Ability to read and comprehend instructions, correspondence, and memos. Ability to write correspondence and be persuasive. Ability to effectively present information in one-on-one and small group situations to customers, clients, payors and other employees of the organization.

Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

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The Genomic/Oncotype Reimbursement Specialist will work directly with patients, prescribing physicians, sales force and payers to educate on the appeals process and support efforts to overturn medical necessity or other claim denials to gain maximum, in network coverage of GHI Products
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If you want to be part of a team that prides itself in teamwork and developing cutting-edge technology at Genomic Health, apply today!