Pharmacy & Medical Benefits Verification Specialist

Amber Specialty Pharmacy•Omaha, NE

2d•Onsite

About The Position

The Pharmacy & Medical Benefits Verification Specialist is responsible for ensuring that accurate, current insurance information is received and maintained and that benefits are verified 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 maximum allowable rates. This is an office-based position in the Benefits Department. The specialist enters information into tracking software, documents communications, completes payer documentation and prior authorization work, and coordinates with patients, caregivers, insurance companies, providers, manufacturers, and nursing agencies. The role also prepares estimated patient costs and shares relevant verification findings and patient updates with appropriate staff. The position follows department workflows and company policies and procedures.

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 and/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 ICD-10, CPT, and HCPCS code classifications.
Knowledge of commercial insurance benefits, Medicare Part D, Medicaid fee-for-service and managed care organizations, and medical insurance benefit designs.
Ability to remain stationary for up to 90% of the time; occasionally move around the office and to meetings or events; operate a computer and office productivity equipment; communicate and exchange accurate information; and observe details at close range.
Ability to pass required pre-employment drug testing, background checks, and health screening if applicable.

Nice To Haves

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

Responsibilities

Enter required data accurately and efficiently into tracking software.
Document calls to and from patients, caregivers, insurance companies, providers, and pharmaceutical companies when applicable.
Notify appropriate staff of information from provider or patient calls that could affect a patient's disease state, medication regimen, or funding method.
Conduct complete benefits investigations, including prior authorization and determining whether coverage is through medical or pharmacy benefits.
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.
Liaise with the Company, insurance companies, copay assistance sources, and provider offices through phone, fax, and email.
Prepare estimates of patients’ benefits costs with pertinent information and attach them to the patient record for 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 referring nurses or coordinators assigned to the team with insurance verification findings, patient issues, and status updates.
Protect confidential patient and employee information and comply with HIPAA-related confidentiality expectations.
Complete required pre-employment screening, including background checks and drug testing.