Senior Clinical Program Specialist

Life Unlimited. At Smith+Nephew, we design and manufacture technology that takes the limits off living.

This role supports the company in achieving its mission to connect patients, providers, and payors to ensure patients can access outstanding technologies and products. The Senior Clinical Program Specialist (Sr. CPS) is responsible for the Reimbursement Hotline team’s accuracy in reporting coverage results based on clinical documentation provided by accounts. The Sr. CPS offers mentorship based on clinical knowledge to support coverage reporting and prior authorization submission based on individual payer criteria.

The Sr. CPS demonstrates proficiency in research and resolution of raised cases, assistance with training and curriculum development, auditing cases, proficiency in workflow systems and processes, payer research, effective communication with the Market Access team, and completion of special projects. The Sr. CPS enforces company policies, procedures, and compliance directives. This role ensures all protected health information (PHI) is managed appropriately within the governing Health Insurance Portability and Accountability Act (HIPAA) guidelines.

What you will be doing?

• Provide clinical guidance to the Hotline team regarding diagnosis coding to report coverage results during the BI phase of the insurance benefit investigation.
• Provide clinical guidance to the Hotline team regarding payer criteria required for submitting Prior authorizations.
• Provide clinical guidance and recommendations for account participation in peer-to-peer reviews and appeals.
• Review commercial and government payer plans with National Payer Relations Managers (NPRMs) to interpret payer criteria and create workbook entries.
• Provide continuing education to the Hotline and Market Access teams via refresher courses, new content training, and editing reporting scripts
• Monitor team performance and report trends to Hotline leadership.

What you need to be successful?

• Graduate from an accredited School of Nursing (e.g., RN or LPN)
• 2+ years’ experience required working in a healthcare reimbursement environment, supporting prior authorizations, and communicating with health plans and healthcare providers
• Knowledge of Medicare, Medicaid, and Private Insurance Reimbursement Methodology
• Able to interpret and analyze detailed medical policies
• Intermediate knowledge of Microsoft-based products/Office Suite (Word, Excel, Outlook, TEAMS, etc.)
• Understanding of Data Entry/Customer Relationship Management programs (Salesforce, Dynamics365, others)
• Familiar with ICD-10, CPT, and HCPCS codes.

Preferred Experience:

• Bachelor’s degree in Nursing (BSN)
• Registered Nurse (RN)
• 2+ years of clinical nursing experience
• Acute care experience preferred
• 2+ years of experience with medical review and applying standard medical review criteria (ex. MCG, Interqual)
• Reimbursement experience within the healthcare industry
• Must have experience with treatment protocols, and other billing and coding guidance
• Experience training or managing teams in a leadership or supportive role
• Experience with reimbursement methodologies for wound care products
• Previous coding and billing experience in the healthcare industry.

Clinical Competencies:

• Support in applying clinical competence and the appropriate application of insurance policies and guidelines to report coverage.
• Apply clinical judgment, to obtain appropriate clinical notes from HCP to submit to insurance companies for prior authorizations.
• Collaborate with various Hotline team members to guide completing accurate reporting of patient coverage based on documentation received from accounts
• Collaborate with Patient Access and Reimbursement Managers (PARMs), to provide clinical guidance for onboarding accounts and strategies to reduce deficiencies in IVR submissions to reduce missing information.
• Collaborate with National Payer Relations Managers (NPRMs) using clinical knowledge to interpret payer policies and create payer coverage guidelines.
• Create training via structured presentations to Reimbursement Hotline and Market Access teams on payer coverage updates, refresher training, and new hire foundational training.
• Provide clinical knowledge and act as a clinical resource to non-clinical staff
• Exceptional customer service skills that align with Smith and Nephew’s best-in-class culture
• Strong attention to quality and details in adherence to standards while ethically maintaining a business perspective
• Strong work ethic and accountability with a willingness to learn, and desire to continually improve<