Summary: The Insurance Reimbursement Coordinator works as a liaison with the patient, prescriber and insurance plan to obtain information on patient benefit designs as well as authorizations for requested services or medications. The Insurance Reimbursement Coordinator will receive, review, and enter requests for benefits and authorization in a timely manner and provide patient and prescriber communications in a manner that adheres to service level standards.
High School diploma or general education degree (GED) required. One year of insurance, pharmacy, medical or professional customer service experience required.
Duties and Responsibilities include the following. Other duties may be assigned.
Act as a liaison between company, patients, insurance, Pharma, and provider's office via phone, fax and/or email communication.
Obtain missing insurance information, diagnosis code and other applicable information by contacting the physician or patient in order to complete the benefits investigation and/or authorization.
Obtain pharmacy and/or medical benefits via phone, insurance website, or via fax for new and/or existing patients prior to any services rendered.
Navigate through payer websites and portals including, but not limited to: MedAccess, webDENIS, Medi-Cal's Online Portal, Partnership Health Online, Express Path (Express Scripts Online Portal).
Research published insurance coverage criteria and locates authorization forms via payer websites/portals and other applicable avenues.
Facilitate prior authorization and/or pre-determination as required by the insurance company
Understands how and when to utilize external authorization systems including insurance and third party portals.
Obtain and review clinical documentation (chat notes, labs, testing, etc.) necessary to complete insurance authorizations.
Initiate authorization, including all available information, based on insurance requirements and completes appropriate follow up to complete pending cases.
Coordinate with prescribers, nurses, office staff to facilitate insurance authorization requirements
Communicate the insurance investigation and authorization outcome with physician's office and/or sales team via fax or email.
Maintains documentation of calls to and from patients, caregivers, insurance and providers.
Answer calls and provide assistance as needed to patients, prescribers and internal departments.
Review inbound faxes and assign to appropriate queues for further action and/or handle as appropriate.
Document benefit investigation and authorization into the patient care management tool.
Process prescriptions through the pharmacy dispensing software as required.
Maintain knowledge of clinical background and insurance requirements for new and emerging therapies
Maintains patient confidentiality.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Ability to comprehend and apply principles of basic math while analyzing data and generating reports.
Ability to apply principles of logical thinking to a wide range of intellectual and practical problems.
To perform this job successfully, an individual should have knowledge of Microsoft products.
Information Security Expectations:
While performing the duties of this job, the employee is required to abide by Diplomat's information security policies, employee handbook and security and privacy regulatory requirements. Each employee is responsible for the secure and appropriate handling of Diplomat information, information received by customers, other companies and/or external parties.
Knowledge, Skills and Other Abilities:
Oral and written communication skills
Ability to work well with various personalities and within a team
Independent and self-motivated
General knowledge of internet navigation and research
Knowledge of email, fax transmission and copy equipment
Ability to problem solve
Participate in continuous quality improvement activities
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to walk; sit and use hands. The employee is occasionally required to stand.
Equal Employment Opportunity and Affirmative Action: Diplomat provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Diplomat complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Diplomat Pharmacy, Inc.