PPS Utilization Review - TMS Care Manager

Job Responsibilities:


* Prepare and submit prior authorization requests for TMS services, including both initial and continuation of treatment.


* Review and compile medical necessity documentation, such as psychiatric evaluations, medication trials, and symptom assessments.


* Communicate with insurance companies to verify benefits, follow up on pending authorizations, and resolve denials or delays.


* Maintain accurate and up-to-date records in the EHR and internal tracking systems for authorizations, approvals, peer reviews, and appeals.


* Collaborate with providers, TMS technicians, and billing staff to ensure clinical documentation and billing accuracy.


* Educate patients on the authorization process, expected timelines, and financial responsibilities.


* Stay current with payer-specific policies, documentation requirements, and TMS-related CPT codes.


* Schedule cortical mappings once insurance approval is on file.


* Manage and update cortical mapping and authorization reports.


* Confirm that all patients are clinically cleared and meet medical necessity criteria for TMS treatment.


* Support medical providers with scheduling and address questions related to TMS patient care and workflows.


* Check the status of all pending authorizations at least every 48 hours.


* Coordinate and complete peer reviews as needed to support medical necessity.


* Other duties as assigned.

Core Competencies:


* Ability to work independently and collaboratively with a team.


* Strong understanding of insurance processes and the TMS authorization lifecycle.


* Solid knowledge of clinical documentation and compliance standards.


* High attention to detail, accuracy, and organizational follow-through.


* Effective coordination of care among clinical, administrative, and billing teams.

Experience & Skills:


* Minimum of 1 year in medical authorizations, care coordination, or behavioral health administration.


* Familiarity with TMS therapy protocols and behavioral health diagnoses.


* Strong knowledge of insurance verification, prior authorization, and payer-specific requirements (Medicare and commercial insurers).


* Proficiency in EHR systems and insurance portals.


* Excellent organizational, communication, and problem-solving abilities.

Physical Demands:

The physical demands outlined here represent those that are typically required of an employee to successfully perform the essential functions of this position.

Reasonable accommodation may be made to enable individuals with disabilities to perform these essential functions.

While performing the duties of this job, the employee is regularly required to do the following:


* Engages in sustained power grasping and pushing/pulling motions


* Exposure to dust, gas, odors, liquids, or fumes


* Intermittent lifting and carrying up to 40 pounds, transporting object usually by hand, arm, or shoulder
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