Job Description

Job Duties and Responsibilities:

• Retrieve prescriptions, purchase order (PO), Doctor’s order (DO), Chart notes, CMNs (Clinical Medical Necessity), and any supporting documentation in compliance with CMS and Insurance/payer’s requirements.
• Request Documents via Fax and/or placing a phone call
• Proactively contact provider/prescribers’ offices to collect missing, incomplete, expired or incorrect documentation required for either Prior Authorization, order fulfillment, or Claims, if applicable.
• Can understand and clearly explain documentation requirements and medical necessity criteria to provider offices or prescribers.
• Proactively contact and engage Members to get assistance on the missing and needed Medical Records or Documents if applicable.
• Partner with patients when needed to help reinforce documentation requests with their provider.
• Build rapport and maintain positive relationships with physicians, referral partners, and patients.
• Provide exceptional and thorough customer service skills when talking to members or patients, resolve additional concern, or transfer to appropriate departments as needed.
• Review current and returned documents for completeness and accuracy prior to submission.
• Identify documentation gaps and proactively request corrections to avoid delays.
• Update and maintain accurate patient billing records on the system.
• Setting up electronic communications to both members/patients, providers, and prescribers.
• Communicate clearly, confidently, and professionally across all levels of the organization.
• Demonstrate strong organizational and time-management skills, with the ability to prioritize and plan
• Handle multiple responsibilities simultaneously without compromising quality or efficiency
• Exhibit a proactive mindset, anticipating needs and resolving issues before they arise
• Work assigned pipelines strategically, prioritizing high-impact opportunities to maximize output.
• Navigate IVRs, gatekeepers, and clinic workflows professionally and persistently.
• Received inbound calls (as needed or if applicable) related to Document Collection concerns, issues, and follow-up.
• Provide input to help elevate process improvements that will benefit patients, clinicians, colleagues, and overall operations.

Workflow & Territory Management

• Manage assigned work queues, providers, or territories to ensure consistency and accountability.
• Batch calls and outreach by provider or region to improve efficiency.
• Document all outreach, outcomes, and next steps clearly within the system (or any applicable tools).
• Collaborate with internal teams (sales, intake, insurance verification, authorization) to resolve issues or delays.

Quality & Compliance

• Ensure all documentation and retrieved Medical Documents meets payer and CMS requirements
• Follow defined SOPs, escalation paths, and zero-tolerance compliance standards.
• Participate in quality audits and ongoing training to continuously improve performance.
• Maintain a patient-first mindset while adhering to regulatory requirements.

Job Required Qualification:

• Minimum 3-year solid experience with US Healthcare Insurance
• At least 1 year work experience in a customer service call center (Voice and Back office)
• Experience with Members/Patients and Prescribers/Provider Calling or Outreach is highly preferred.
• Experience with Prior Authorization process and protocols is highly preferred.
• Excellent Customer service skills, including phone and interpersonal skills.
• Experience and knowledgeable in checking prescriptions, purchase order (PO), Doctor’s order (DO), chart notes, CMNs (Clinical Medical Necessity), and any supporting documentation in compliance with CMS and Insurance/payer’s requirements.
• Experience and knowledgeable in handling different type of insurances (Medicaid, Medicare, Medicare Advantage plans, and Commercial)
• Understanding in validating vital information, like CPT codes, DX codes, NPI numbers, Revenue codes, and Provider Tax IDs, etc.
• Knowledge of all Provider types – such as, Billing Provider, Referring Provider, Rendering Provider etc.
• Ability to manage high volume workloads and meet performance targets
• Work history of excellent attendance and punctuality
• Computer proficiency in MS Word, Excel, and Outlook preferred
• Typing accuracy of 35 wpm minimum
• Database data entry experience preferred.
• Strong knowledge and use of the English language, both written and verbal
• Thrive in challenging situations with a focused and calm approach
• Possess strong organizational skills and prioritization
• Ability to work independently and meet deadlines.
• High comfort level working with culturally diverse team members and clients.

Preferred Qualifications:

• Startup / rapid growth experience
• Life sciences, pharmaceutical, or medical device experience.
• Knowledge of medical terminology preferred.
• Knowledge in DME Products (e.g. Diabetic Supply, Enteral Nutrition Supplies / Medical Foods, incontinence supply, urology supply, ostomy supply, Prosthetic Devices, and Breastfeeding Supplies.)