Pharmacy & Medical Benefits Verification Specialist

Hy-Vee, Inc.•Omaha, NE

5d•Onsite

About The Position

At Amber Specialty Pharmacy, our commitment to patient care is unmatched. Enjoy fulfillment in a career where you have the opportunity to make a positive impact on patients with complex and chronic conditions. This is an office-based position. The role is responsible for ensuring accurate insurance information is received, stored, and current benefits are verified upon receipt of new and/or renewal referrals for patients. This includes a thorough pharmacy and medical benefits investigation to determine appropriate and accurate coverage of the prescribed medication to ensure the Company will be reimbursed at maximum allowable rates and in a timely manner.

Requirements

Working knowledge of all necessary computer software to perform job duties.
Knowledge of primary code classifications: ICD-10, CPT and HCPCS.
Knowledge of general Commercial insurance benefits, Medicare Part D benefit structure, Medicaid FFS and Managed Care Organizations and medical insurance benefit designs.
Proficient with MS Excel, Word, and Outlook.
Demonstrated ability to meet tight deadlines.
Must be detail oriented with a high degree of accuracy and efficiency.
Ability to work as a team and with all levels of internal management and staff, as well as outside clients and vendors.
Working knowledge of the healthcare industry, specifically the pharmacy industry.
HIPAA trained and/or the ability to work with and protect extremely confidential patient and employee information.
One (1) year experience in Benefits.
High school diploma or equivalent.
Must be able to remain in a stationary position – up to 90% of the time.
The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc., and traverse conferences, meetings, and remote events.
Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer.
The ability to communicate information and ideas so others will understand. Must be able to exchange accurate information in these situations.
The ability to observe details at close range (within a few feet of the observer).
Must lift and traverse the area to move paper and supplies to use the equipment.

Nice To Haves

Preferred knowledge in State Renal Programs and their application to transplant and specialty patients.

Responsibilities

Ensuring accurate insurance information is received, stored, and current benefits are verified upon receipt of new and/or renewal referrals for patients.
Performing a thorough pharmacy and medical benefits investigation to determine appropriate and accurate coverage of the prescribed medication.
Ensuring the Company will be reimbursed at maximum allowable rates and in a timely manner.
Entering data requirements accurately and efficiently into tracking software.
Maintaining documentation of calls to and from patients, caregivers, insurance companies, providers, and Pharma (if applicable).
Notifying appropriate staff of relevant information gathered during calls to provider or patient that may affect a patient’s disease state, medication regimen, or method of funding.
Performing complete benefits investigation, including prior authorization and medical vs pharmacy determination.
Completing all payer documentation including Medicare Certificates of Medical Necessity and DME Information Forms.
Preparing and transmitting eligibility inquiries to determine coverage using the pharmacy processing system.
Acting as a liaison between the Company, insurance companies, co-pay assistance sources, and provider’s offices via phone, fax, and e-mail communications.
Creating patient’s estimated cost of benefits with all pertinent information and attaching it to the record for use by the Customer Care Center of Excellence.
Maintaining the established workflow within the Benefits Department and adhering to the company/department’s Policy and Procedure manual.
Coordinating manufacturer or nursing agency support when home teaching is required.
Contacting referring nurses/coordinators according to assigned team regarding insurance verification findings and patient issues and status updates.
Adhering to all company policies as indicated in the handbook and directives issued by management.
Completing background checks, including drug testing, criminal conviction history, references, OIG, and other relevant information as allowed by city, state, agency, organizations, or federal requirements/law.
Passing a pre-employment drug test, background check, and health screening (if applicable).