Under general supervision of the Manager, Benefit Verification, provides oversight of all benefit investigation for referrals, including major medical, PBM, Medicare, Medicaid, secondary, supplemental, patient financial assistance, and others as required. Responsible for oversight of all prior authorizations, re-authorizations, adjudication exceptions, and financial outcomes related to benefit verifications and team activities. Coordinates and delegates daily team workflow to ensure productivity objectives are met; quality verifications and exceptional customer service are achieved, including team performance goals. Collaborates with other teams, including managed care, sales, clinical, and pharmacy operations to facilitate patient on-boarding and physician communication. Represents the team as a subject matter expert with external customers, such as payers and pharmaceutical manufacturers. PRIMARY DUTIES AND RESPONSIBILITIES:
- Ensures workload is distributed among benefit verification associates.
- Ensures team communicates and complies with deadlines, including expected turn around times of referrals and authorizations.
- Ensures timely re-authorization for prior authorizations, to prevent expiration of authorization, in order to ensure payment and continuation of patient therapy.
- Responsible for quality of verifications, as shown by internal QA review activities, triage review, as well as reimbursement activities tied to those patients verified.
- Reviews error reports and enters corrections into computer to ensure accuracy of data.
- Responds to inquiries regarding verifications.
- Handles escalated situations, including complex or difficult benefit investigation and/or communication with physician offices and patients.
- Responsible for exceptional customer service with patients and physician offices.
- Manages communication with commercial sales team regarding patient statuses.
- Represents the Benefit Verification team for applicable disease focus and program areas in a professional manner to external customers including payers, manufacturers, and providers.
- Manages patient financial assistance process, including ensuring that all avenues are explored and exhausted to enable a patient to afford medication therapy.
- Responsible for proper documentation and communication of benefit investigation results and patient assistance efforts, including documentation in pharmacy management system.
- Aggressively pursues opportunities for business to keep patients on service.
- Works with Managed Care team and contracting to identify and seek contracting opportunities and contract issues, including expired contracts and/or reimbursement rates as they arise in the operation.
- Complies with all appropriate policies, procedures, safety rules and regulations.
- Coordinates referral hand-off with scheduling team.
- Coordinates with all branches to ensure timely and accurate delivery of referrals and tasks for incoming information pertaining to patient records.
- Provides direct support to staff.
- Handles team supervision, coaching, discipline, payroll, scheduling, and other HR related activities.
- Trains and provides direction on procedures and processes to associates.
- Ensures a continuous quality improvement customer service approach by proactively identifying areas of improvement and communicating those ideas to the team.
- Coordinates responses and resolutions to issues with appropriate internal and external parties.
- Actively participates in round table discussions with other operational team managers and supervisors, and others as needed.
- Maintains and promotes positive and professional working relationships with associates and management.
- Performs related duties as assigned.
Requires broad training in fields such as business administration, accountancy, sales, marketing, computer sciences or similar vocations generally obtained through completion of a four year Bachelor's Degree Program or equivalent combination of experience and education. Normally requires three (3) years directly related and progressively responsible experience in a healthcare related call center environment or physician's office, and a minimum of 2-3 years of supervisory experience. MINIMUM SKILLS, KNOWLEDGE AND ABILITY REQUIREMENTS:
- Working knowledge of healthcare insurance landscape including, but not limited to major medical, PBM, Medicare, Medicaid, secondary, supplemental, patient financial assistance, and others.
- Ability to promote a positive team environment
- Attention to detail, quick study, self-motivated, proactive, and the ability to work independently.
- Ability to communicate effectively both orally and in writing
- Strong interpersonal skills
- Excellent presentation skills
- Strong analytical skills
- Pharmacy management system experience
- Insurance experience, preferably in benefit investigation or reimbursement activities in the pharmacy space
- Strong organizational skills; attention to detail
- Ability to resolve associate issues quickly and efficiently
- Ability to manage team with specific metrics and goals and support team in achieving those goals
- Ability to represent a positive and professional image
- Presents the Benefit Verification team with external customers in a professional manner
- Strong knowledge of Microsoft Word, Excel, Power Point and Outlook
- Ability to consistently meet deadlines
- Ability to implement processes resulting in satisfactory audit practices
The work environment characteristics described here are representative of those an associate encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions: The noise level in the work environment is generally quiet to moderate. PHYSICAL AND MENTAL REQUIREMENTS:
The physical demands described here are representative of those that must be met by an associate to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions:
- Sedentary physical activity requiring reaching, sifting, lifting, finger dexterity, grasping, feeling, repetitive motions, talking and hearing.
- Visual requirement is for close vision, distance vision, peripheral vision and ability to adjust focus.
- 50% or more time is spent looking directly at a computer.
- Associate is frequently required to stand, walk (or otherwise be mobile).
- Ability to deal with stressful situations as they arise.