Responsible for verifying patient eligibility, coordinating benefits, running test claims, and determining patient coverage/responsibility for services. Handles inbound and outbound calls with customers, physician offices, patients or third-party providers about the company’s products or services following standard SOPs and procedures, working under direct supervision. Ensures all contacts receive efficient and courteous service.
Job Responsibilities
- Respond to all levels of inbound Pharmacy Benefit Manager (PBM) and major medical insurance related phone calls.
- Resolves questions and problems submitted by customers and Pharmacy Benefit Manager (PBM) following established guidelines and standard SOPs and procedures. Utilizes all available information to choose the best solution and resolve customer and PBM concerns.
- Requests and loads PBM and/or Major Medical insurance plans.
- Processes all non-clinical PBM rejections which may include but not limited to rejections for plan limits, coverage termed or prior authorization.
- Assists physicians in the prior authorization process including initiation of prior authorizations.
- May be cross-trained and/or work on Major Medical (MM) and Specialized PBM Plans.
- Verifies benefits for Major Medical via online resources or over the phone. Confirms network status, reviews FDA guidelines, and prior authorization requirements to ensure payment of claims.
- Resolves questions and problems submitted by customers and Major Medical plans following established guidelines and standard SOPs and procedures. Utilizes all available information to choose best solutions and resolves customer and plan covers.
- Facilitates the reimbursement windshields for PBM major medical claims.
- Identifies and assesses individual customer or patient needs and provide education on or assist with grant applications, complex funding needs, commercial copay assistance enrollment along with appropriate action to satisfy those needs.
- Provides primary support and expertise for specialized programs such as the patient assistance program or special handling.
- Manages Pharma requirements including but not limited to warm transfers, bridge/quick start, enhanced prior authorization and appeal support.
- May administer order queue such as Submission Problems or Waiting for Payment.
- Documents contact interactions, records details, complaints, comments, and actions taken.