Post-Service Appeals Case Manager

Noctrix Health is redefining the treatment of chronic neurological disorders with clinically validated therapeutic wearables. Our team of medical device specialists, neuroscientists, and consumer electronics engineers is dedicated to delivering prescription-grade therapy with an outstanding user experience. We have pioneered the world’s first drug-free wearable therapy, clinically proven to alleviate symptoms in adults with drug-resistant Restless Legs Syndrome (RLS). Be part of our mission to transform healthcare, improve lives, and drive meaningful change with Noctrix Health.

We are seeking an experienced and detail-oriented Post-Service Appeals Case Manager to manage medical necessity appeals and support the successful resolution of denied durable medical equipment (DME) claims after service has been provided. This role is responsible for evaluating claim denials, reviewing clinical documentation, researching payer requirements, developing appeal strategies, and independently managing post-service appeals through resolution.

The ideal candidate brings strong experience in DME reimbursement, denied claims, and post-service appeals, with the ability to independently interpret payer policies, assess medical necessity documentation, and navigate complex reimbursement challenges. This individual will serve as a key liaison among healthcare providers, payers, billing teams, patients, and internal stakeholders to ensure appeals are accurate, timely, clinically supported, and compliant with applicable payer requirements.

This position reports to the Director, Patient Access.

Responsibilities:

• Independently manage post-service medical necessity appeals for DME claims from initial denial review through preparation, submission, follow-up, and final resolution
• Review denied claims to identify denial rationale, documentation deficiencies, authorization issues, and the appropriate appeal or reconsideration strategy
• Review medical records, physician notes, orders, clinical documentation, and supporting materials to determine whether documentation supports medical necessity and applicable payer coverage criteria
• Research and interpret payer policies, medical necessity guidelines, coverage criteria, reimbursement requirements, and appeal procedures
• Prepare and submit first-level, second-level, and other applicable appeals within payer-specific and regulatory deadlines
• Draft clear, concise, and clinically supported appeal letters that directly address payer denial rationale and demonstrate medical necessity
• Identify missing or insufficient clinical documentation and collaborate with healthcare providers and clinical teams to obtain information required to strengthen appeals
• Communicate with insurance companies, payer representatives, and claims departments regarding appeal status, reconsiderations, documentation requirements, and final determinations
• Maintain comprehensive tracking of appeals, including submissions, correspondence, follow-up activities, deadlines, payer decisions, and outcomes
• Maintain accurate case notes and patient information within CRM, billing, and case management systems
• Navigate payer-specific medical necessity criteria, documentation requirements, submission processes, and appeal timeframes
• Apply knowledge of benefit investigations, prior authorizations, retro-authorizations, claims workflows, and their relationship to post-service appeals
• Partner closely with Billing and Reimbursement teams to communicate appeal status, outstanding requirements, approvals, and next steps
• Support prior authorization and other reimbursement appeals as business needs require
• Identify recurring denial trends, documentation deficiencies, and payer-specific challenges and communicate findings to leadership and cross-functional stakeholders
• Provide reporting and insights to leadership regarding claim denials, appeal outcomes, payer trends, and opportunities for process improvement
• Educate healthcare providers and internal stakeholders on documentation requirements, medical necessity criteria, and common payer denial reasons
• Collaborate with Patient Access, Reimbursement, Billing, Clinical, and other cross-functional teams to resolve complex reimbursement issues
• Develop and maintain tools, resources, appeal templates, and training materials related to payer requirements, medical necessity, denial management, and post-service appeals
• Consistently meet established quality, accuracy, productivity, and turnaround-time expectations
• Maintain patient confidentiality and ensure all activities are performed in accordance with company policies, HIPAA, and applicable privacy requirements

Requirements:

• Bachelor’s degree in Business, Healthcare Administration, Health Sciences, or a related field preferred; equivalent relevant experience will be considered
• Minimum of 5 years of healthcare industry experience, preferably within medical device, DME, reimbursement, patient access, billing, or related functions
• Minimum of 2 years of medical device reimbursement experience involving DME products
• Experience managing post-service appeals, claim denials, or medical necessity appeals
• Demonstrated understanding of DME reimbursement, benefit investigations, prior and retro-authorizations, claims processing, and appeals
• Ability to independently research and interpret payer policies, medical necessity criteria, coverage requirements, and appeal procedures
• Experience reviewing clinical documentation and determining whether records adequately support medical necessity
• Ability to independently prepare, submit, track, and follow up on complex appeals
• Strong understanding of payer deadlines and the importance of timely and accurate appeal submissions
• Strong analytical and problem-solving skills with the ability to independently investigate and resolve complex claims-related issues
• Excellent written communication skills, including the ability to prepare clear, persuasive, and clinically supported appeal documentation
• Excellent verbal communication and collaboration skills when working with healthcare providers, payers, patients, and internal stakeholders
• Strong organizational and case management skills with the ability to manage a high-volume appeals workload and multiple deadlines
• Strong attention to detail and commitment to documentation accuracy and compliance

Preferred Qualifications:

• Direct experience managing post-service DME medical necessity appeals
• Experience independently managing appeals through multiple levels of payer review
• Experience working with commercial insurance plans and government payers
• Experience with payer medical policies, medical necessity criteria, and reimbursement guidelines
• Experience with retro-authorization and authorization-related claim denials
• Experience identifying denial trends and using data to improve reimbursement processes
• Experience with CRM, billing, or case management systems; Salesforce experience preferred
• Experience collaborating with Billing, Reimbursement, Clinical, and Patient Access teams
• Experience developing payer resources, appeal templates, training materials, or process documentation
• Experience working within a high-growth medical device or healthcare organization

Key Measures of Success:

• Timely submission and follow-up of post-service appeals
• Accuracy and completeness of appeal documentation
• Appeal overturn and successful resolution rates
• Adherence to payer-specific and regulatory deadlines
• Effective management of appeal volume and case turnaround times
• Identification and reduction of recurring denial and documentation issues
• Quality and accuracy of CRM and case management documentation