Pharmacy & Medical Benefit Verification Specialist

General Function:

Responsible for ensuring accurate insurance information is received, stored and current benefits are verified upon receipt of new and/or renewal referrals for patients. This is inclusive of a thorough pharmacy and medical benefits investigation to determine appropriate and accurate coverage of the prescribed medication to ensure the Company will be reimbursed at maximum allowable rates and in a timely manner.

Reporting Relations:

Accountable and Reports to: Lead Benefits Specialist, Senior Manager - Revenue Cycle

Positions that Report to you: None

Primary Duties and Responsibilities:

•  This is an office-based position.

• Working knowledge of all necessary computer software to perform job duties.  Enters data requirements accurately and efficiently into tracking software.

• Maintains documentation of calls to and from patients, caregivers, insurance companies, providers and Pharma (if applicable).

• Notifies appropriate staff of relevant information gathered during calls to provider or patient that may affect a patient’s disease state, medication regimen or method of funding.

• Knowledge of primary code classifications: ICD-10, CPT and HCPCS.

• Knowledge of general Commercial insurance benefits, Medicare Part D benefit structure, Medicaid FFS and Managed Care Organizations and medical insurance benefit designs.

• Must be able to perform complete benefits investigation, including prior authorization and medical vs pharmacy determination. The individual will also need to complete all payer documentation including Medicare Certificates of Medical Necessity and DME Information Forms.

• Knowledge of pharmacy processing system to prepare and transmit eligibility inquiries to determine coverage.

• Acts as a liaison between the Company, insurance companies, co-pay assistance sources and provider’s offices via phone, fax and e-mail communications.

   Creates patient’s estimated cost of benefits with all pertinent information and attaches to record for use by Customer Care Center of Excellence.

• Must maintain the established workflow within the Benefits Department and adhere to the company/department’s Policy and Procedure manual.

• Responsible for coordinating manufacturer or nursing agency support when home teaching is required.

• Contacts referring nurses/coordinators according to assigned team regarding insurance verification findings and patient issues and status updates.

• Adheres to all company policies as indicated in the handbook and directives issued by management. Has reviewed Policy and Procedure manual.

• Preferred knowledge in State Renal Programs and their application to transplant and specialty patients.

Knowledge, Skills, Abilities, and Worker Characteristics:

• Proficient with MS Excel, Word, and Outlook  Demonstrated ability to meet tight deadlines.

• Must be detail oriented with a high degree of accuracy and efficiency.

• Ability to work as a team and with all levels of internal management and staff, as well as outside clients and vendors.

Education and Experience:

• Working knowledge of the healthcare industry, specifically the pharmacy industry

• HIPAA trained and /or the ability to work with and protect extremely confidential patient and employee information.

• One (1) year experience in Benefits

• High school diploma or equivalent

Physical Requirements:

• Must be able to remain in a stationary position –up to 90% of the time

• The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc., and traverse conferences, meetings, and remote events.

• Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer.

• The ability to communicate information and ideas so others will understand. Must be able to exchange accurate information in these situations.

• The ability to observe details at close range (within a few feet of the observer).

Working Conditions:

• Normal office environment.

Equipment Used to Perform Job:

• Computers, keyboards, mouse, monitors, fax, and/or headsets for phone work. Software specific to the position, including but not limited to Microsoft Outlook and Skype. Must lift and traverse the area to move paper and supplies to use the equipment.

Contacts: 

• Frequently interact with co-workers, intradepartmental staff of the Company, managers, leaders, Vendors, and customers.

Confidentiality:

• The position Interactions with medical personnel, patients, and accesses proprietary and medical (HIPAA) information in various interactions and matters.

This position is required to complete background checks, including drug testing, criminal conviction history, references, OIG, and other relevant information as allowed by city, state, agency, organizations, or federal requirements/law.