The Insurance Verification Coordinator is responsible for reviewing and assessing incoming referrals to ensure all requirements are met before the benefit investigation is initiated and/or transferred to the pharmacy for processing and dispensing. The Insurance Verification Coordinator will set up patient referrals for adjudication and make the necessary outreach to the Pharmacy Benefit Manager (PBM) to resolve rejected claims and/or contact prescribers to collect additional information or data needed for a successful claim submission (i.e. insurance information, prescription, etc.)
- Create new and edit a patient record in the Customer Relationship Management (CRM) system by entering demographics, insurance information, prescription, and verification outcomes from incoming referrals (incoming referrals are received via incoming phone calls or prescriber web portal).
- Complete a benefits investigation on all received referrals to ensure a patient has valid coverage prior to transferring the patient record to the dispensing specialty pharmacy partner.
- Make outreach to PBM to verify benefits and/or resolve rejected claims. Obtain the necessary information needed to obtain successful adjudication (.i.e. patient demographics, insurance information, etc.).
- Make initial and follow up outreach to the prescriber in the event that a rejection is due to an authorization. The Insurance Verification Coordinator will confirm the process of how to obtaining an authorization with the payer. Facilitate the authorization process by either contacting the payer to initiate the authorization via phone or facsimile with information available from the prescription, or by contacting the prescriber and providing them the information that is needed for the prescribers office to submit the authorization directly to the payer (i.e. prior authorization form, clinical information, etc.).
- Handle incoming customer service inquiries from patients, prescribers, insurance companies, external partners, or internal partners. Research and resolve problems in a timely manner. Escalate issues as necessary to the Team Lead, or Supervisor.
- Initiate outbound phone call to the patient to explain the outcome of the benefit investigation. Make outreach to prescriber via phone or facsimile to inform of unresponsive patients in the event that the patient is not being responsive to telephone calls or mailed letters.
- Employee is responsible for adhering to the quality, production, and turnaround standards associated with the department and/or assigned program.
- Other duties as assigned
- High school diploma or General Education Development (GED) certificate required
- Pharmacy Technician Licensure per state regulation, preferred but not required.
- Two or more years of reimbursement experience in specialty pharmacy and/or high volume retail pharmacy location required.
- Knowledge of medical terminology. Ability to read a prescription preferred but not required. Experience initiating product authorization requests required.
- Detail oriented, good analytical skills, advanced problem solving skills, and excellent verbal and written communication skills, with demonstrated ability to communicate with others at all levels
- Experience with data entry functionalities and computer proficiency in Microsoft Office applications
- Willingness to work a flexible schedule during peak volumes, including overtime and Saturdays as necessary.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to sit.
- The employee must occasionally lift and/or move up to 10 pounds.
- The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The noise level in the work environment is usually moderate.
- Must be flexible on schedule and hours
- Overtime may be required from time to time
- Must be willing to work weekends if required to meet company demands