Sr. Prior Authorization Representative - Accredo

Accredo Health Pittsburgh , PA 15201

Posted 3 weeks ago

POSITION SUMMARY

Obtains required documentation, verifies insurance benefits, completes shipments, and may complete quality assurance audits as needed. Processed invoices in preparation for billing and transfer payor information regarding billing and reimbursement criteria. Negotiates pricing as necessary and authorizes patient service. Ensures data accuracy in Rx Home including payer pricing. May conduct invoice editing and revenue reconciliation for booking inventory.

ESSENTIAL FUNCTIONS

  • Contact benefit providers and/or payers to gather policy benefit limitations and ensure services provided are reimbursable; deductable amounts, co-payments, effective date, levels of care, authorization, visit limitations, documentation required to process claims).

  • Documents all communication.

  • Facilitate communication for acceptance or denial of new patient referral/change in therapy.

  • Provide updates to physician and sales on the status of pending referrals.

  • Provide billing and reimbursement requirements; assist with billing, payer, and patient issues.

  • Submit required documentation.

  • Notify patient or responsible party of possible financial responsibility before start of service if business rules require.

  • Negotiate pricing based on pricing grids for non-contracted payers.

  • Authorize patient services and ensure proper payer pricing is indicated in Rx Home.

  • Contact/inform branch staff if no payer source is available.

  • Ensure accounts requiring authorizations and re-authorizations are identified, secured, and updated in Rx Home prior to each shipment.

  • Notify service delivery staff if authorization cannot be obtained.

  • Update patient information with address/benefit changes per payer request and make correction to ensure payment.

  • Conduct financial quality assurance reviews (DVR, shipment QA, insurance and authorization screens, etc.) of patient and payer related data post start of care and shipment to validate and ensure services provided will be reimbursed.

  • May conduct invoice editing and daily revenue accuracy reconciliation as required for the SDU in accordance with the Invoice Editing processes and essential duties.

  • Special projects as assigned.

QUALIFICATIONS

  • High School Diploma or GED required; Bachelor's Degree preferred.

  • 3 5 years relevant experience.

  • Working knowledge of Microsoft Office.

  • Excellent Customer Service Skills - patience to explain details and processes repeatedly, excellent phone presentation and communication skills.

  • Demonstrated ability to handle challenging customers in a professional manner, ability to adapt in a dynamic work environment and make decisions with minimal supervision.

  • Advance problem solving skills and the ability to work collaboratively with other departments to resolve complex issues with innovative solutions.

  • Ability to work a flexible schedule.

ABOUT THE DEPARTMENT

Through our range of health care products and services offered, Accredo team members provide in-depth care for patients with chronic health conditions like hemophilia, oncology, rheumatoid arthritis and growth hormone deficiency. In addition to health care products, we provide comprehensive management services including outcomes measurement, counseling, clinical care management programs, social services and reimbursement services. By performing in these very high-touch roles, employees have a daily opportunity to make a positive impact on their patients' lives.

ABOUT EXPRESS SCRIPTS

At Express Scripts, we dare to imagine a better health care system, and we're driven to make it happen. Where some see obstacles, we see possibilities. We're challengers, difference-makers and opportunity-seekers, united with our partners in pursuit of a simpler, more sustainable system and better health for all.

We have always acted first to take on the toughest challenges. We uniquely partner across the health care ecosystem to uncover opportunities, take action, advance health care and deliver better outcomes like no one else can. We believe health care can do more. We are Champions For BetterSM.

Express Scripts, part of Cigna Corporation, unlocks new value in pharmacy, medical and beyond to further total health for all.


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Sr. Prior Authorization Representative - Accredo

Accredo Health