Reimbursement Specialist

Job Description

Job Description

Position Objective: The Reimbursement Specialist researches and investigates drug or treatment specific coverage and benefits to assist MDOs (medical doctors’ offices).

Accountability: The incumbent will report to the Program Manager.

Essential Functions:

• Handles benefit request investigations submitted by MD offices. Investigations to be conducted via test claim, eBV and/ or phone. 
• Contacts insurance companies directly to obtain patient’s specialty pharmacy and prescription benefits.
• Updates pharmacy claim processing info i.e. BIN, PCN, ID and Group numbers in the patient record.
• Document detailed pharmacy benefit results with the appropriate information regarding patient’s pharmacy benefits and network pharmacy details according to the established triage rules and procedures.
• Handling, detecting and fixing errors within the system to ensure proper benefit retrieval.
• Identify and escalate priority issues to the Case Manager or Program Manager.
• Route information and coverage results appropriately to the Case Manager.
• Follow up on Prior authorization status as required based on business rules.
• Document all call information according to standard operating procedures.
• Review referral and case for information accuracy and completeness, including but not limited to, patient demographics, pharmacy card processing information, prescription quantity, dose, directions and diagnosis code.
• Document missing information if any and relay to the Case Manager for HCP or patient outreach as needed.
• Performs other duties as assigned by the Program Manager or the Team Lead.

Knowledge, Skills & Abilities:

• Associate’s degree or equivalent from a two-year college, technical school or certificate program in pharmacy and/or healthcare, preferred. High School Diploma or GED, required.

• 1-2 years' experience in pharmacy or insurance verification environment (i.e. hub services, pharmacy, doctor's office, health plan member services, etc.), required.

• Experience in pharmacy benefit investigation, retail pharmacy or specialty pharmacy adjudication, required.

• Knowledge in call center telephony technology

• High level of customer service, interpersonal skills, and highly effective in working objectively with a diverse group of people.

• Excellent verbal/written communication skills, self-discipline, and attention to detail.

• Proficient in data entry, computer skills, and able to learn the department’s software system.

• Must be a team player willing to accept organizational and team goals, and function with minimal supervision.

• Maintain HIPAA patient confidentiality, as well as discretion regarding proprietary company information.

• Adaptable, able to shift gears and focus based on company and team needs.