You will be responsible for processing pharmacy claims, ensuring they are completed accurately and promptly to meet the expectations of clients (patients, healthcare providers, or insurance companies). Timeliness and precision are critical to avoid delays or issues with reimbursement.
Triage rejected pharmacy insurance claims:
If a pharmacy claim is rejected by insurance, your job will be to analyze and resolve the issue. This involves determining the patient's pharmacy benefits and why the claim was rejected. Understanding the insurance coverage is key to resolving such issues.
Assist in initiating prior authorization requests:
Prior authorizations (PA) are often required by insurance companies for certain medications or treatments. You'll assist in initiating PA requests by gathering necessary information from healthcare providers to submit to insurance companies for approval.
Identify the correct prior authorization form:
There are different PA forms depending on the patient's insurance provider. Your role involves identifying which form is needed and ensuring that the correct one is used for each case.
Coordinate with prescribers and medical offices:
You'll work with prescribers (doctors or other healthcare providers) and medical offices to make sure all necessary information is included in the PA forms. This may involve communicating with these offices to ensure accuracy and completeness.
Follow up on prior authorization requests:
After submitting the PA request, you will be responsible for following up with the medical offices and insurance companies to check on the status of the request and ensure it is processed in a timely manner.
Communicate status of prior authorizations:
Keeping both patients and providers informed about the status of the PA requests is essential. You'll be tasked with conveying whether the request has been approved, denied, or is still under review.
Coordinate with medical offices to handle Appeals:
If a prior authorization is denied, your role may involve helping coordinate the appeals process. You'll work with medical offices to gather the necessary information and resubmit appeals to the insurance company.
Respond to internal inquiries:
Internal departments may have questions about prior authorization requests. You'll need to be able to provide answers or clarifications, working cross-functionally with other teams to ensure a smooth workflow.
Maintain compliance with patient assistance program guidelines:
You must ensure that all activities related to prior authorizations and pharmacy claims comply with the guidelines set forth by patient assistance programs, which help patients access medications at lower costs.
Document information and data discovery:
Accurate documentation is key to maintaining transparency and proper record-keeping. You will need to log all relevant information and discoveries according to company policies and operating procedures.
Research information using available resources:
You will be required to use available resources (such as databases, online tools, or reference materials) to gather the information necessary for completing claims or prior authorizations, or resolving issues.
Maintain confidentiality:
Given that you will be working with sensitive patient data, it's essential to maintain confidentiality and adhere to privacy regulations (such as HIPAA) to protect patient and proprietary information.
Requirements:
High school diploma or GED (Bachelor's degree preferred):
A high school diploma is the minimum educational requirement, but a bachelor's degree is preferred. A degree, especially in healthcare or a related field, may make you a stronger candidate.
One year of healthcare (pharmacy preferred) experience:
You should have at least one year of experience in a healthcare or pharmacy-related role, particularly involving third-party claims resolution (working with insurance or managing claims). Experience in a pharmacy setting is preferred.
Strong verbal and written communication skills:
As the role requires frequent communication with medical offices, providers, and internal teams, strong verbal and written communication skills are critical for explaining complex information clearly and professionally.
Technical skills and analytical ability:
The role requires a solid understanding of technical tools (likely related to pharmacy claims and prior authorizations). You will need to demonstrate good judgment and strong analytical skills to evaluate claims, interpret insurance coverage, and resolve issues.
Passion for patient care:
A commitment to patient care is key, as the role involves ensuring that patients receive the medications they need in a timely manner. Your work will directly impact patient access to medications, so empathy and a patient-first attitude are essential.
Team-oriented and cross-functional collaboration:
You will be part of a team and need to work closely with other departments (like medical offices, insurance companies, and internal teams). Strong teamwork and collaboration skills are important for achieving success in this role.
Strong technical aptitude and ability to learn new software:
You will need to be comfortable with learning and using complex software systems. The ability to quickly adapt to new tools, especially related to pharmacy claims and prior authorization management, is essential.