Access & Reimbursement Specialist

UnitedHealth Group • Las Vegas, NV

9h • Remote

About The Position

Optum is a global organization focused on delivering care aided by technology to improve health outcomes. The Access & Reimbursement Pharmacy Specialist will be responsible for benefit verification research and initiation of pharmacy claims, aiming to obtain patient access. This includes ongoing follow-up on prior authorizations and appeals, as well as identifying and securing financial assistance. The role requires accurate adherence to directions, thorough research, and communication of prescription insurance coverage requirements, along with comprehensive knowledge of Medicare, Medicaid, and commercial plan structures. This position operates under the direct supervision of an Access & Reimbursement Supervisor and offers the flexibility to telecommute from anywhere within the U.S.

Requirements

• 2+ years of hands-on Pharmacy Claims Processing experience and Benefit Verification in a pharmacy setting
• Ability to work 8-hour shifts Monday through Friday with a start time between 10:00am-11:00am EST
• Must be 18 years of age OR older

Nice To Haves

• 2+ years of Prior Authorization processing experience in an insurance or pharmacy setting
• Valid license, registration and/or certification, good standing, to practice as a Pharmacy Technician as required by the Board of Pharmacy in the state employed
• Specialty Pharmacy experience
• Pharmacy Accreditation experience
• Previous work history working in a matrixed environment, call center, operations environment
• Ability to work independently and as a team, and maintain good judgment and accountability
• Demonstrated ability to work well with health care providers
• Meet deadlines and proactively communicates roadblocks
• Speak, listen and write in a clear, thorough and timely manner using appropriate and effective communication tools and techniques
• Strive for thoroughness and accuracy when completing tasks
• Ability to work independently
• Strong knowledge of Internet navigation and research
• Willingness to learn and grow in the position
• Participate in continuous quality improvement activities
• Be a team player and collaborate across functions
• Ability to multitask across different applications and work queues

Responsibilities

• Knowledgeable and proficient in pharmacy benefit structure of all major payer types including government and commercial payers
• Knowledgeable and proficient in the entire pharmacy prior authorization and appeals process for prescriptions medications
• Navigate calls to pharmacy benefit manager to determine and obtain patient benefit structure details, initiate overrides, and obtain contracting requirements
• Completes test claims or electronic verification of benefits when applicable
• Accurately collect the information required for each program and capture the information in a Customer Relationship Management system (CRM) or database
• Coordinates with board licensed healthcare professionals including nurses, pharmacists, or supervised pharmacy interns for information needed to complete Prior Authorizations, Appeals and third-party financial assistance forms
• Follows up with pharmacy plans and third-party financial assistance organizations for general information, status updates and determination details within specified timeframes
• Effectively explains prior authorization and appeal approval or denial details with customers in a way that is easily understood to fit the audience's needs
• Keeps current with the requirements and eligibility criteria for copay assistance from public, private, and non-profit organizations related to assigned programs to assist customers with enrolling into third party financial assistance opportunities when applicable. This includes researching foundations available to support the patients' holistic needs
• Keeps current with existing treatment trends, treatment standards and updated indications related to assigned programs to complete Prior Authorization and Appeal forms
• Maintains a working knowledge of program guidelines, FAQ’s, products, and therapeutic areas related to programs within the Frontier Therapies portfolio
• Responsible for reviewing, interpreting, and reacting to data provided by clients and customers
• Coordinates the triage of patient prescription to the appropriate partner for fulfillment or administration
• Communicates customer statuses to the appropriate parties at specified intervals or as needed
• Resolve customer issues through basic troubleshooting and escalate potential problems or issues that require management’s attention in a timely manner
• Maintains company, employee and customer confidentiality as well as compliance with all HIPAA regulations
• Provide recommendations to IT partners on system enhancements to better drive performance and quality
• Completes special duties or projects assigned by leadership

Benefits

• Competitive base pay
• Full and comprehensive benefit program
• Performance rewards
• Management team who demonstrates their commitment to your success
• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
• Development for other roles you may be interested in

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed