Prior Authorization Appeals Specialist

Join Our Team at IVX Health!

IVX Health is seeking a Prior Authorization Appeals Specialist to provide specialized expertise in resolving complex pre-service authorization denials and appeals. This role works closely with providers, payers, Prior Authorization teams, and market partners to navigate payer requirements, coordinate supporting documentation, and help resolve barriers to patient access for medically necessary infusion and injection therapies. The ideal candidate brings strong knowledge of prior authorization and appeals processes, excellent problem-solving skills, and the ability to serve as a resource for complex cases and denial-related workflows.

What You'll Do

• Manage Denials & Appeals: Review pre-service authorization denials, determine appropriate next steps, and coordinate reconsiderations, appeals, peer-to-peer reviews, and payer exception requests within applicable timeframes.
• Navigate Payer Requirements: Interpret payer policies, medical necessity criteria, utilization management requirements, coverage guidelines, and denial rationales to determine appropriate resolution pathways.
• Coordinate Clinical Documentation: Partner with providers and internal teams to obtain letters of medical necessity, clinical notes, supporting records, and other documentation needed to support reconsiderations and appeals.
• Resolve Complex Cases: Monitor denial and appeal inventory, conduct required follow-up, escalate complex cases and payer barriers, and serve as a resource for challenging authorization and denial-related issues.
• Collaborate Across Teams: Communicate denial outcomes, documentation requirements, and escalation options with providers, market teams, Prior Authorization, Sales, Operations, Contracting, and leadership to support timely case resolution.
• Support Quality & Process Improvement: Identify denial trends, recurring payer barriers, and opportunities to improve workflows, reduce preventable denials, and strengthen the accuracy and consistency of authorization processes.
• Provide Training & Expertise: Develop and maintain workflows, SOPs, playbooks, and training materials while supporting onboarding, training, and knowledge sharing across the Prior Authorization team.
• Work Effectively in a Remote Environment: Maintain productivity, responsiveness, data security, and strong communication while working remotely, adhering to IVX Health policies and performance expectations.

Essential Competencies & Skills

• Advanced understanding of prior authorization, medical necessity, denial, reconsideration, and appeals processes.
• Ability to interpret and apply payer policies and coverage requirements across complex and non-standard scenarios.
• Strong analytical, problem-solving, and critical-thinking skills with exceptional attention to detail and accuracy.
• Strong written and verbal communication skills with the ability to effectively collaborate with providers, payers, and internal stakeholders in a remote environment.
• Ability to manage a high-volume workload while prioritizing complex and escalated cases.
• Proficiency with EMR systems, payer portals, and Microsoft Office applications.
• Ability to train, mentor, and serve as a knowledgeable resource to peers.
• Strong understanding of commercial and government payer requirements, including Medicare and Medicaid.

Required Education & Experience

• High school diploma or equivalent required; Associate's or Bachelor's degree preferred.
• 3–5 years of experience in prior authorization, reimbursement, denial management, appeals, or infusion healthcare required.
• Demonstrated experience managing complex authorization or denial-related cases across multiple payer types.
• Experience working with commercial and government payers, including Medicare and Medicaid.

Preferred Experience

• Experience in infusion or specialty pharmacy prior authorization.
• Experience handling complex medical necessity denials and appeals.
• Experience developing workflows, SOPs, playbooks, or training materials.
• Experience serving as a subject matter expert or resource to peers.