DME/Prior Authorization Partner - Boston, MA

Who is Gather Health?

Gather Health is a collective of outreach partners, care partners, clinicians and, most importantly, patient partners who work together to reshape lives and communities. We bring hands-on social and medical care to our patients and work around their needs, both within our care facilities and in their homes. We work alongside local leaders to build communities and provide tailored care experiences that serve the seniors that live within them. When we Gather, we show love, compassion, community, and care.

What is this role about?

We are seeking a Prior Authorization Partner, who has pharmacy and durable medical equipment responsibilities, to support Gather Health, an at-risk primary care group for seniors.

What are some of the day-to-day duties?

This clinic-based role will include responsibilities for pharmacy prior authorizations and DME coordination. Some of the day-to-day duties will include but are not limited to:

• Pharmacy Prior Authorization Responsibilities:
• Manage the submission, follow up, and completion of pharmacy prior authorization requests
• Collaboration with PCPs to determine if an alternative medication may be acceptable based on insurance coverage preferences
• Verify that approved prior authorizations result in successful claim processing at the pharmacy
• Maintain detailed progress notes in the Electronic Medical Record
• Provide regular updates to patients and external partners (e.g., pharmacies, insurance companies) regarding the status of prior authorizations
• Communicate with the pharmacy to confirm successful claim adjudication
• Additional duties as assigned
• Durable Medical Equipment (DME) Coordination Responsibilities
• Accept and process DME requests submitted by Primary Care Physicians (PCPs) and external partners (e.g., therapists, home health agencies)
• Follow up with DME suppliers to confirm that all necessary medical criteria documentation is provided. Ensure the documentation meets insurance and regulatory requirements
• Communicate with patients to provide status updates and confirm that ordered DME products are received
• Additional duties as assigned

What are the minimum requirements for this position?

• At least one year of experience in processing prior authorizations, insurance referral coordination, and/or DME coordination
• Familiarity with Medicare and Medicaid programs as well as value-based care models a plus
• Experience with basic office tools such as email, Outlook calendar, etc.
• Strong verbal, written, and reading comprehension skills in English
• Ability to work regular office hours Monday through Friday
• Ability to work for any employer in the United States

What are the “nice to have”, preferred requirements?

• Effective communication and interpersonal skills
• Self-motivated and capable of working independently with moderate supervision
• Willingness to work with complex populations to resolve medical issues quickly
• Strong prioritization, flexibility, and adaptability skills
• Bilingual in Haitian Creole and/or Spanish

What are the traits of someone most likely to succeed in this role?

• Organized – manages time effectively and operates efficiently
• Motivated – thrives in a busy environment
• Friendly – people enjoy their company because of their joyful nature
• Compassionate – they treat people with kindness
• Patient – they are not easily frustrated or flustered
• Resourceful – they are creative when it comes to problem solving
• Positive – sees glass as is half full vs. half empty
• Reliable – takes responsibilities seriously and always shows up on time

What are the hours for this position?

• Monday – Friday 8:00am - 5:00pm

Why should I join Gather Health?

• We are a mission-based organization that is passionate about changing the way seniors experience primary care
• Our business model is unique and on the cutting-edge of the primary care industry
• Our leadership team is comprised of experienced individuals who are committed to creating not only the best patient experience, but also an amazing employee experience for our colleagues
• We are intentionally building a strong company culture and providing a compassionate and joyful work environment
• The organization was conceptualized, founded, and launched by experienced co-founders with a track record of success in the healthcare space
• We offer competitive pay and benefits for our Full-Time colleagues, including:
• Paid Time Off (total of 3 weeks per year PTO that accrues with each pay period)
• 11 Paid Holidays
• Medical insurance coverage (health, dental, vision) with no waiting period for enrollment
• Short and Long-Term disability insurance at no cost to you
• Basic life insurance coverage at no cost to you
• 401K plan with 100% employer match up to 4% of income
• Employee Assistance Program at no cost to you
• Free onsite parking
• Supplemental benefits available for discounted prices (legal services, Aflac, hospital indemnity, accidental death & dismemberment, etc.)

Gather Health is an Equal Opportunity Employer. All employment decisions are made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status, or any other basis as protected by federal, state, or local law.

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