Communicate with patients to obtain information required to process prescriptions, refills, access benefits and apply charges against co-pay cards.
Investigate and verify insurance benefits and eligibility for pharmacy and medical third-party claims for assigned cases.
Obtain prior authorizations; initiate requests, track progress, and expedite responses from insurance carriers and other payers, and maintain contact with customers to keep them continuously informed.
Review for accuracy of prescribed treatment regimen prior to submission of authorization
Facilitate appeals process between the patient, physician, and insurance company; compose clinical appeals letters based of specific denial reason and patient’s clinical presentation and coordinate appointment of representative document.
Complete status check with insurance company regarding receipt/outcome of prior authorization and appeal; obtain approval information and activates copay cards based of eligibility and specific drug prescribed.
Track, report and escalate service issues arising from requests for authorizations, financial assistance or other issues that delay service.
Notify patients when their prescription has been transferred and follow up with specialty pharmacy to confirm the prescription was received (in some jurisdictions)
Coordinate verbal transfer by a pharmacist if specialty pharmacy has no record of prescription (in some jurisdictions); confirm with patient that prescription was received from alternate specialty pharmacy.
Complete a series of assessments mandated by either manufacturer contracts or operations and facilitate patient enrollment with manufacturer Hubs when required.
Document case activity, communications, and correspondence in computer system to ensure completeness and accuracy of patient contact records.
Ensure that work activities are conducted in compliance with regulatory requirements and the organization defined standards and procedures, and in a manner that provides the best available level of service and quality.
Perform or assist with any operations, as required to maintain workflow and to meet business needs.
Must be able to perform the essential job functions of this position with or without reasonable accommodation.
Participate in any variety of meetings and work groups to integrate activities, communicate issues, obtain approvals, resolve problems, and maintain specified level of knowledge pertaining to new developments, requirements, and policies.
Report any misconduct, suspicious or unethical activities to the Compliance Officer
Participate in surveys conducted by authorized inspection agencies.
Participate in the pharmacy’s Performance Improvement program as requested by the Performance Improvement Coordinator
Participate in pharmacy committees when requested.
Participate in in-service education programs provided by the pharmacy.
Perform other related duties as assigned by supervisor.
