Prior Authorization Appeals Specialist

IVX Health

. Review pre-service authorization denials, determine next steps, and coordinate reconsiderations, appeals, peer-to-peer reviews, and payer exception requests within applicable timeframes.

Posted 10/23/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in prior authorization processes, denial management, and appeals, with a strong ability to interpret payer policies and medical necessity criteria. Proven skills in communication, collaboration, and training within a remote work environment, ensuring effective workflows and documentation management.

Highest-signal resume keywords

Prior Authorization ManagementDenial ManagementPayer Policy InterpretationAnalytical Problem-SolvingEMR Systems Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Prior AuthorizationDenial ManagementAppeals ProcessesMedical Necessity CriteriaUtilization ManagementReconsideration ProcessesPayer Exception RequestsData SecurityWorkflow DevelopmentDocumentation Management

Soft Skills

Strong Communication SkillsCollaborationAttention to DetailCritical ThinkingMentoring

Tools & Technologies

EMR SystemsPayer PortalsMicrosoft Office

Industry Keywords

MedicareMedicaidCommercial PayersGovernment PayersHealthcare Reimbursement

About the role

Key responsibilities & impact

Review pre-service authorization denials, determine next steps, and coordinate reconsiderations, appeals, peer-to-peer reviews, and payer exception requests within applicable timeframes.
Interpret payer policies, medical necessity criteria, utilization management requirements, coverage guidelines, and denial rationales.
Partner with providers and internal teams to obtain letters of medical necessity, clinical notes, supporting records, and other documentation.
Monitor denial and appeal inventory, conduct follow-up, escalate complex cases and payer barriers, and support challenging authorization issues.
Communicate denial outcomes, documentation requirements, and escalation options with providers, market teams, Prior Authorization, Sales, Operations, Contracting, and leadership.
Identify denial trends and payer barriers and improve workflows to reduce preventable denials and strengthen authorization accuracy.
Develop and maintain workflows, SOPs, playbooks, and training materials; support onboarding, training, and knowledge sharing.
Maintain productivity, responsiveness, data security, and communication while working remotely and following IVX Health policies.

Requirements

What you’ll need

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.
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.

Benefits

Comp & perks

Medical, Dental, and Vision Coverage
Prescription Drug Coverage and Telemedicine Services
Health Savings Account (HSA), Health Reimbursement Arrangement (HRA), and Flexible Spending Options
401(k) Retirement Plan with Company Match
Life, AD&D, and Disability Insurance
Accident, Critical Illness, and Hospital Indemnity Coverage
Fertility and Family Planning Support
Tuition Reimbursement and Certification Assistance
Continuing Education and Professional Development Resources
Employee Assistance Program and Wellness Support
Paid Time Off
Volunteer Time Off and Charitable Giving Match
Employee Referral Bonus Program