Senior Insurance Verification & Prior Authorization Specialist - DME

Apex Health Group is a durable medical equipment provider in Falls Church, Virginia, supplying high-end devices that help patients recover from surgery and manage chronic symptoms at home. This role owns the benefits intake process on every order, including eligibility and coverage verification, prior authorization, and consistent follow-through to keep an order moving until the patient receives a device.

Orders hit roadblocks every day in our industry — a payer won’t give a straight answer on coverage, an authorization disappears into a fax queue, or a medical policy isn’t published anywhere we can find it. We need someone who works through those situations to find the right answers and keep the order moving rather than logging the issue and waiting.

Speed and accuracy are both critical. Our volume is growing quickly, and clinics prefer to work with a partner who gets devices to their patients quickly, while patients need accurate information about their coverage and costs. The work here sets the stage for success through the rest of the order process, and getting it wrong costs us — or worse, a patient — real money. We need someone who can move quickly while staying attentive to detail.

KEY RESPONSIBILITIES

•   Benefits Verification & Eligibility: Run benefits verification and eligibility checks on new orders. Communicate accurate coverage to reps and patients, including deductible, network status, medical policy criteria, authorization requirements, and patient responsibility. Serve as the internal resource when sales or customer service has a coverage question.

•   Prior Authorization: Determine whether prior authorization or pre-certification is required, assemble the clinical documentation, and submit through the payer’s preferred channel. Confirm receipt and track each submission through to a decision.

•   Payer Portal Access: Manage portal registration and user access for new and existing payers, and move submissions off fax wherever a portal or ePA channel is available.

•   Clearing Roadblocks: When a submission stalls or a payer’s answer doesn’t make sense, identify the right department, the right portal, a direct contact — finding an approach that gets the process unstuck and to a resolution.

•   Denials & Appeals: Work authorization denials and medical necessity requests. Gather additional clinical documentation, submit reconsiderations, and coordinate peer-to-peer reviews.

•   Systems & Payer Expansion: As we grow, help build the processes and tools for this function, including our new EMR/workflow platform. Support payer enrollment and credentialing as we add locations, states, and networks. Credentialing experience is welcome but not required.

THE IDEAL CANDIDATE

•   Experience: 3 years in benefits verification, benefit investigation, or prior authorization, including hands-on work in payer portals (Availity, NaviNet, payer-specific portals, Medicare DMEPOS contractor portals). DME or HME experience preferred; home health, infusion, and specialty pharmacy backgrounds translate well. Familiarity with compression / E065x codes, standard written orders, and Medicare DMEPOS documentation requirements is a strong plus.

•   Detail-oriented and analytical: Careful verification of plan, codes, and effective dates. Comfort reading and interpreting medical policy, and the judgment to question a payer rep's answer when it conflicts with published criteria.

•   Resourceful & Organized: Persistence in following up on stalled submissions and escalating within the payer when needed. Ability to manage a high-volume caseload with a reliable system for tracking open orders and follow-up dates.

•   Clear communicator: Clear written and verbal explanation of coverage details to sales reps, customer service staff, and patients.

COMPENSATION & DETAILS

•   Compensation: $65,000 - $80,000 depending on experience, reviewed annually.

•   Benefits: Health insurance, 401k with matching, 15 days of paid time off plus holidays.

•   Growth: As our volume grows, the role can expand to include ownership of our payer relationships, credentialing and contracting, and building a team around this function. We are looking for someone who wants to own this work long term.

•   Schedule: Full-time, onsite in our Falls Church, VA office. This role works closely with our sales and customer service teams throughout the day.

Apex Health Group LLC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, genetic information, protected veteran status, or any other protected characteristic as outlined by federal, state, or local laws.