Medicare D Billing Representative

Job Title

Medicare D Biller

Job Description

PharMerica, a part of Brightspring Health Services, is a long-term care pharmacy services provider that supplies medications, clinical support, and pharmacy management to healthcare organizations across the United States. The Medicare D Biller serves as a primary liaison for the Clinical Hub, maintaining proactive communication with pharmacists, healthcare facilities, physicians, and Prescription Drug Plans (PDPs) regarding therapeutic interchange opportunities and prior authorization requests. This role is responsible for researching payment denials by contacting insurance plans to determine the cause of denials and coordinating with facilities to obtain supporting information. Additionally, the Medicare D Biller updates and documents prior authorizations, including clinical justifications, while ensuring the accurate and timely completion of all required authorization forms. The position requires a high level of attention to detail when initiating, processing, and tracking prior authorizations on behalf of customers. Working closely with EMAR systems, healthcare facilities, and clinical teams, the Medicare D Biller serves as a key point of contact throughout the prior authorization process, ensuring efficient coordination, thorough documentation, and successful resolution of authorization requests.

Benefits and Perks

Medical, Dental, Vision insurance Health Savings & Flexible Spending Accounts (up to $5,000 for childcare) Tuition discounts & reimbursement 401(k) Company Paid Time Off* Shift Differential DailyPay Pet Insurance Employee wellness and discount programs

Responsibilities

• Act as a resource to the facilities in obtaining information completing necessary documentation or following up on outstanding claims
• Individual with an understanding of Insurance and Medicaid formularies and processes including the prior authorization processes
• Makes outgoing calls to Facilities, Plans, and Physician's offices as needed to obtain approvals
• Works with Client Billing Service Offices, Pharmacy Directors, customers and prescription drug plans to effectively communicate and resolve customer issues
• Performs other tasks as assigned
• Achieves productivity goals with regard to calls/claims per hour as determined by the Director and Clinical Hub Manager
• Provide clinical support to members of the RxAllow team regarding prior authorization concerns / submissions
• Conducts job responsibilities in accordance with the standards set out in the Company's code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and State Laws, and applicable professional standards
• Familiar with the claim adjudication process
• Develop a strong understanding of the insurance verification, adjudication, back-end billing process and become a subject matter expert on the insurance queues and billing workflow

Qualifications

• High School Diploma, Associates degree; Bachelor's degree preferred
• Certified Pharmacy Technician or Medical Assistant Certification desired
• Third party Medical Billing experience
• EMAR system knowledge
• One to three years of pharmacy experience preferred
• Three years of call center experience preferred
• Understanding of insurance and medicaid formularies and processes including the prior authorization processes
• Familiar with the claim adjudication process
• Proficiency in Microsoft Office programs
• Prioritize work to meet daily and competing deadlines

About Our Line of Business

PharMerica, an affiliate of BrightSpring Health Services, delivers personalized pharmacy care through dedicated local teams, serving health care providers such as skilled nursing facilities, senior living communities, and hospitals. We also cater to individuals with behavioral needs, infusion therapy needs, seniors receiving in-home care, and patients with cancer. Operating long-term care, home infusion, and specialty pharmacies across the nation, we combine the personal touch of a neighborhood pharmacy with the resources of a national network. Our comprehensive solutions, backed by industry-leading technology and regulatory expertise, ensure accurate medication access, cost control, and compliance with best-in-class clinical standards. We are committed to enhancing resident health, reducing staff burdens, and supporting our clients' success.