Reimbursement Prior Authorization Specialist II

Company Description

Guardant Health is a leading precision oncology company focused on guarding wellness and giving every person more time free from cancer. Founded in 2012 Guardant is transforming patient care and accelerating new cancer therapies by providing critical insights into what drives disease through its advanced blood and tissue tests real-world data and AI analytics. Guardant tests help improve outcomes across all stages of care including screening to find cancer early monitoring for recurrence in early-stage cancer and treatment selection for patients with advanced cancer. For more information visitand follow the company onLinkedInX (Twitter)andFacebook.

As a Reimbursement Specialist II Prior Authorization you are a seasoned expert within the revenue cycle team driving impact through deep knowledge of insurance processes payer policy and prior authorization strategy. You play a key role in ensuring patients receive timely access to care while maximizing reimbursement outcomes for the organization.

You will independently manage the full prior authorization lifecyclenavigating complex payer policies securing timely approvals and resolving escalated reimbursement issues. With your extensive background in healthcare billing and payer engagement you will lead efforts to streamline processes troubleshoot complex denials and collaborate with team members and ordering physician offices to ensure seamless communication.

In collaboration with Finance Client Services Account Managers and our billing technology partners you will champion best practices and contribute to a high-functioning compliant billing operation. Youll help build and maintain comprehensive documentation of payer requirements and support process improvement initiatives that increase efficiency and effectiveness across the department.

Key Responsibilities:

Revenue Cycle Management:

• Manage the full prior authorization lifecycle including navigating complex payer policies and securing timely approvals.
• Actively review submit track and resolve Prior Authorization inquiries using appropriate systems and tools (SalesForce/Telcor/Emails/Fax/Phone/Portals) until final approval is obtained.
• Resolve escalated rejected authorizations issues and streamline processes for efficiency.
• Research system notes to obtain missing or corrected insurance or demographic information.
• Prepare and submit necessary medical records documentation and justification to insurance companies.
• Ensure all required documentation is complete and accurate to avoid delays in authorization.
• Manage faxes emails phone calls and respond to voicemails and emails.
• Maintain comprehensive documentation of payer requirements and support process improvement initiatives.
• Follow appropriate HIPAA guidelines.
• Performs other added responsibilities as assigned to support the overall efficiency of the department.
• All job duties must be performed in a manner that demonstrates the company Leadership Attributes and support of the Mission & Values of the company.

Cross-functional Collaboration:

• Communicate effectively with cross-functional teams and ordering physician offices to identify and address inefficiencies impacting ASP and claims adjudication processes.
• Work closely with staff to investigate and resolve delays rejections or discrepancies related to claims submissions for optimal reimbursement.

Travel Requirements:

This role may require some travel that may include but is not limited to:

• Participating in corporate events and quarterly/biannually/annually meetings to connect and share innovative strategies.
• Engaging in development opportunities and conferences that will enhance your skills and knowledge empowering you to lead initiates effectively.
• Initiating and participating in teambuilding activities in person and collaborating with cross-functional teams to foster a strong united workplace culture.

Qualifications

• Minimum of 3 years of healthcare reimbursement experience with a strong focus on prior authorization insurance coordination payer relations and appeals.
• Expert-level knowledge of Medicare Medicaid IPA and commercial payer authorization policies and appeals processes.
• Demonstrated success in managing complex high-priority claims including overturning denials through advanced appeal strategies and external reviews.
• Proficiency with revenue cycle tools and systems such as Xifin/Telcor payer portals and Salesforce.
• Proven track record of working cross-functionally with internal teams and external stakeholders to resolve reimbursement challenges.
• Exceptional attention to detail self-motivated organizational abilities and driven to identify process improvements that enhance operational performance.
• Experience with laboratory billing workflows and national/regional payer requirements is highly desirable.
• Demonstrated proficiency with using a computer hardware and PC software specifically Microsoft Office Suite Adobe Acrobat PDF particularly Excel and have above average typing skills
• Experience with contacting and follow up with insurance carriers.
• Analytical mindset with experience in data analysis and process optimization.
• Ability to work independently and handle confidential and sensitive information with utmost discretion.
• Must be able to work cohesively in a team-oriented environment and be able to foster good working relationships with others both within and outside the organization
• Excellent communication and interpersonal skills to facilitate collaboration across department with an ability to distill complex issues for both technical and non-technical audiences.

Hybrid Work Model: This section is applicable to onsite employees who are eligible for hybrid work location as specified by management and related policies. Guardant has defined days for in-person/onsite collaboration and work-from-home days for individual-focused time. All U.S. employees who live within 50 miles of a Guardant facility will be required to be onsite on Mondays Tuesdays and Thursdays. We have found aligning our scheduled in-office days allows our teams to do the best work and creates the focused thinking time our innovative work requires. At Guardant our work model has created flexibility for better work-life balance while keeping teams connected to advance our science for our patients.