Pharmacy & Medical Benefits Verification Specialist

Hy-Vee, Inc.•Omaha, NE

7d•Onsite

About The Position

At Amber Specialty Pharmacy, the Benefits Specialist supports patient care by ensuring insurance information is accurate, current, and documented for new and renewal patient referrals. The role conducts thorough pharmacy and medical benefits investigations to determine coverage for prescribed medications and support timely reimbursement at allowable rates. This is an office-based position in the Operations department and is non-exempt. The specialist communicates with patients, caregivers, insurance companies, providers, manufacturers, and other support organizations; documents interactions; and shares relevant findings with appropriate staff. The role also prepares patient cost estimates, coordinates support when home teaching is required, and follows department workflows and company policies. The position reports to the Lead Benefits Specialist and Senior Manager - Revenue Cycle, and has no direct reports. The schedule is Monday through Friday, with no weekends. Shifts vary within the hours of 7 a.m. to 7 p.m. Central Time to total 40 hours per week. The work takes place in a normal office environment.

Requirements

At least one year of experience in Benefits.
High school diploma or equivalent.
Working knowledge of the healthcare industry, specifically the pharmacy industry.
HIPAA training or the ability to work with and protect highly confidential patient and employee information.
Proficiency with Microsoft Excel, Word, and Outlook.
Ability to meet tight deadlines.
Strong attention to detail and a high degree of accuracy and efficiency.
Ability to work as part of a team and with internal management and staff, external clients, and vendors.
Knowledge of primary code classifications, including ICD-10, CPT, and HCPCS.
Knowledge of commercial insurance benefits, Medicare Part D benefit structure, Medicaid fee-for-service and managed care organizations, and medical insurance benefit designs.
Ability to perform complete benefits investigations and payer documentation tasks.

Nice To Haves

Knowledge of State Renal Programs and their application to transplant and specialty patients.

Responsibilities

Ensure accurate insurance information is received, stored, and current when new and renewal referrals arrive.
Enter data accurately and efficiently into tracking software and maintain documentation of calls with patients, caregivers, insurers, providers, and pharmaceutical companies when applicable.
Notify appropriate staff of information from provider or patient calls that may affect a patient's disease state, medication regimen, or funding method.
Conduct complete benefits investigations, including prior authorization and medical-versus-pharmacy coverage determinations.
Complete payer documentation, including Medicare Certificates of Medical Necessity and DME Information Forms.
Use the pharmacy processing system to prepare and transmit eligibility inquiries to determine coverage.
Act as a liaison among the company, insurers, copay assistance sources, and provider offices through phone, fax, and email.
Prepare patient estimated cost-of-benefits information and attach it to the patient record for use by the Customer Care Center of Excellence.
Maintain established Benefits Department workflows and follow company and department policies and procedures.
Coordinate manufacturer or nursing agency support when home teaching is required.
Contact assigned referring nurses or coordinators with insurance verification findings, patient issues, and status updates.
Follow company policies and management directives.