Patient Access Appeals Specialist

Job Title: Patient Access Appeals Specialist

Company Overview:

Pulivarthi Group is a premier global provider of staffing and IT technology solutions, renowned for delivering exceptional services tailored to each client's unique needs. With a steadfast commitment to excellence, we merge expertise with innovation, ensuring cost-effective solutions of the highest quality. Our diverse client base spans healthcare, finance, government, and beyond, reflecting our adaptability and proficiency across industries. Operating in the United States and Canada, we pride ourselves on aligning with clients' cultures, deploying top-tier talent, and utilizing cutting-edge technologies. Pulivarthi Group stands as a beacon of reliability, efficiency, and innovation in the realm of staffing solutions.

Job Overview/Summary:

The Patient Access Appeals Specialist is responsible for developing and managing insurance appeal submissions to support patient access to therapy. This role collaborates closely with internal teams, physicians, payers, and field representatives to ensure timely, compliant, and well-supported appeals. The specialist leverages clinical knowledge, payer policies, and regulatory guidelines to strengthen cases and improve approval outcomes while maintaining strict adherence to compliance standards.

Responsibilities:

• Partner with internal teams to secure access support and drive effective pull-through with payers.

• Develop clear, compelling, and well-supported patient appeal letters aligned with payer policies.

• Thoroughly review medical records and documentation for completeness and identify missing information required for appeal submission.

• Stay current on payer coverage policies, patient eligibility requirements, and healthcare reform impacts affecting therapy access.

• Utilize applicable medical policies, clinical publications, and supporting documentation to strengthen appeal arguments.

• Meet established productivity metrics and timeliness standards.

• Provide timely responses to patients, physicians, office staff, and field representatives.

• Review payer communications (approval/denial letters) and share findings with appropriate stakeholders.

• Monitor and ensure resolution of appeals and grievances in accordance with company policies and procedures.

• Report all product-related complaints within required timeframes.

• Maintain accurate case documentation and status updates.

• Ensure strict compliance with HIPAA and patient confidentiality requirements.

• Adhere to company Code of Conduct, industry compliance standards, and applicable governmental regulations.

• Represent the organization professionally while upholding ethical business practices.

• Perform other duties as assigned.

Primary Skills:

• Insurance appeals and grievance management

• Medical record review and documentation analysis

• Payer policy interpretation

• Appeal letter development

• Healthcare compliance (HIPAA)

• Cross-functional collaboration

Secondary Skills (Good to Have):

• Knowledge of healthcare reimbursement processes

• Experience in medical device or therapy access support

• Familiarity with clinical publications and medical policy research

• Customer service and stakeholder communication expertise

• Intermediate to advanced computer skills

Qualifications:

• Bachelor’s degree or equivalent experience preferred

• Experience in healthcare insurance appeals, reimbursement, or patient access services

• Strong written communication skills for drafting appeal letters

• Knowledge of payer coverage policies and medical necessity criteria

• Excellent organizational and time management skills

• Ability to work independently in a high-volume, deadline-driven environment

• Strong ethical standards and commitment to regulatory compliance

Benefits/Perks:

• Competitive compensation

• Professional development opportunities

• Collaborative work environment

• Exposure to reimbursement strategy and healthcare policy

• Comprehensive benefits package

Equal Opportunity Statement:

Pulivarthi Group is proud to be an equal opportunity employer. We are committed to building a diverse and inclusive culture and celebrate authenticity. We do not discriminate on the basis of race, religion, color, national origin, gender, gender identity, sexual orientation, age, marital status, disability, protected veteran status, or any other legally protected characteristics.