Job Details

Description

Shift Hours: During training, the hours would be 8am-4:30pm. Once the technician is released to the floor we can discuss shifts options. We currently have the follow shifts: 7am-3:30pm 8am-4:30pm 9am-5:30 pm Additional later shifts may be added to support the business. Our ours are 7am-7pm.

The primary function of the Insurance Analyst I is to provides best-in-class customer services to patients, Health Care Providers (HCPs) and their staff through referral and call management by investigating patients’ insurance benefits and financial assistance opportunities, in addition to processing and monitoring prior authorizations to assist the patient in starting or continuing therapy. This position will be a subject matter expert in insurance billing, claims processing, and prior authorizations. This position liaises between departments, payors, and providers to comprehensively determine patients’ overall prescription coverage. The Insurance Analyst I handle patient requests received by phone or electronically (fax, Humira Complete Pro, or other systems) and would complete related outbound calls. This position works collaboratively with other areas of the Pharmacy to maximize patients’ access to care.

Responsibilities:

• Provide subject matter expertise on medical and prescription insurance coverage/ verification, claim billing, medication prior authorization and appeal filing, and alternate financial assistance opportunities.
• Accurately documents information in the appropriate systems and formats.
• Communicate the status of the referral to the physician and the patient via phone, fax, and/or the core pharmacy system as per established policies and procedures.
• Assist offices through the entire documentation and filing process for prior authorizations and appeals.
• Monitor the status to ensure a rapid turnaround resulting in procurement of the drug product for the patient.
• Use internal and web tools and communicate and collaborate with health insurance payors and providers to investigate pharmacy and medical benefits.
• Obtain and confirm information to maintain Pharmacy Solutions’ payor intelligence resources.
• Meet or exceed department standards relative to performance metrics. Take responsibility and accountability for the day-to-day execution of tasks and is responsible for providing periodic progress reports on goals and metrics. Work cross-functionally to identify and share opportunities for process and productivity improvement and to troubleshoot and/or resolve situations, taking ownership as needed.
• Decide whether to reinvestigate or accept obtained benefit verification based on reasonableness and accuracy.
• Determine whether to escalate issues/concerns to management for review, guidance, and resolution. Participate in quality monitoring and in identifying and reporting quality issues.
• Enter patient demographic and health insurance information into the hub information system and notify the physician of any incomplete or incorrect insurance information
• Understand and comply with all required training, including adherence to federal, state, and local pharmacy laws, HIPAA policies and guidelines, and the policies and procedures of Pharmacy Solutions
• Identifies potential Adverse Event situations for reporting to Pharmacovigilance ensuring client meets FDA regulations.
• Completes all required training and performs all functions in the position e.g., Soft Skills certification, product and disease overviews.
• Perform additional tasks, activities, and projects as deemed necessary by management.

Qualifications:

• High school diploma or GED equivalent required. Degree preferred.
• 1-3 years of work experience in a healthcare or reimbursement setting ; call center preferred.
• Previous experience in a call center environment, healthcare office, corporate setting, or healthcare insurance provider or pharmacy is highly desirable.
• Must have thorough understanding and knowledge of commercial and government pharmacy and medical insurance programs, billing, alternate funding resources, reimbursement processes, prior authorization and appeal filings, and specialty pharmacy operations.