Under the general supervision of the Senior Nurse Manager, this position is responsible for\ various reimbursement functions in addition to serving as a liaison between manufacturer representatives and/ or specialty pharmacy contacts in order to effectively monitor patient status, triage and dispense data to prevent potential interruptions in patients' therapy and resolve errors in data reporting. Proactively monitors program reports to assess specialty pharmacy adherence to business requirements.
PRIMARY DUTIES AND RESPONSIBILITIES:
1. Lead and facilitate daily conference calls with specialty pharmacy contacts (and client, if applicable) to monitor patient progress, reconcile data discrepancies, research missing data, handle inquiries and provide updates as requested
2. Coordinate and process copay requests including but not limited to patient status requests, copay assistance, prior authorization, billing inquiries, obstacles, eligibility inquiries, and claims processing challenges.
3. Create and maintain action log, agendas and minutes for each specialty pharmacy meeting.
4. Handle inbound/outbound calls from all applicable customers including but not limited to specialty pharmacy contacts, client contacts, third party vendors and internal team resources.
5. Triage and/or approve referrals to specialty pharmacies daily or as needed.
6. Reference and implement Business Requirements Document (BRD) as it pertains to operating procedures, validation of incoming data from the Specialty Pharmacy, and identifying and escalating data feed issues internally and externally.
7. Identify needed system enhancements and/or reports and participate in requirement review, testing and implementation.
8. Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
9. Maintains frequent phone contact with provider representatives, third party customer service representatives, pharmacy staff, and case managers.
10. Processes any necessary insurance/patient correspondence.
11. Provides all necessary documentation required to expedite payments. This includes demographic, authorization/referrals, National Provider Identification (NPI) number, and referring physicians.
12. Coordinates with inter-departmental associates to obtain appropriate medical records as they relate to the reimbursement process
13. Provides training and support to inter-departmental associates.
14. Independently and effectively resolves advanced accounts with minimal supervision.
15. May travel to sites to present program services and further build relationship with sites.
16. Maintains confidentiality in regards to patient account status and the financial affairs of clinic/corporation.
17. May have responsibility for particular geographic regions, physician office sites.
18. Works on problems of diverse scope where analysis of data requires evaluation of identifiable factors.
19. Demonstrates excellent judgment in selecting methods and techniques for obtaining solutions. Networks with internal and external personnel in own area of expertise.
20. Typically determines methods and procedures on new assignments.
21. Coordinate data transfer with client and ensure data integration during transition of product support services from another HUB provider.
22. Share best practices and learning opportunities with reimbursement team
23. Identify and report Adverse Events
24. Performs related duties and special projects as assigned.
EXPERIENCE AND EDUCATIONAL REQUIREMENTS:
Requires broad training in fields such as business administration, accounting, computer sciences, medical billing and
coding, or similar vocations generally obtained through completion of a two year associate's degree program, technical vocational training, or equivalent combination of experience and education. Three (3) to five (5) years directly related and progressively responsible experience preferred.
MINIMUM SKILLS, KNOWLEDGE AND ABILITY REQUIREMENTS:
1. Ability to communicate effectively both orally and in writing.
2. Strong interpersonal skills.
3. Strong negotiating skills.
4. Strong mathematical skills.
5. Strong analytical skills.
6. Strong organizational skills; attention to detail
7. Proficient knowledge of pharmacy operations
8. Proficient knowledge of HCPCS, CPT, ICD-9 and ICD-10 coding.
9. Global understanding of commercial and government payers.
10. Ability to proficiently use Microsoft Excel, Outlook and Word.
11. A seasoned, experienced professional with a full understanding of area of specialization; resolves a wide range of
issues in creative ways. This job is fully qualified career-oriented position.
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