Responsible for all new referrals for the Infusion Services, including obtaining prior authorizations and verifying eligibility and benefits.
Responsibilities
Processes all incoming work orders, interviewing client/referral source to secure demographic and financial and qualifying data, and securing verification and authorization of benefits as appropriate.
Directs inquiries and referrals to the appropriate individual and/or service line.
Coordinates incoming calls from both referral sources and patient/customers.
Initiates and coordinates prior authorization requests to third party payers and maintains a working knowledge of third party payer guidelines.
Supports documentation compliance by recording patient interactions, updating case notes in pharmacy systems, and maintaining privacy requirements.
Processes prior authorization requests by collecting clinical documentation, completing payer-specific forms using templates, submitting requests, and tracking status.
Verifies insurance coverage by reviewing patient insurance cards, checking formulary information, and documenting coverage details.
Supports financial assistance enrollment by collecting patient eligibility information, completing manufacturer copay applications, and submitting paperwork to program administrators.
Coordinates specialty pharmacy referrals by processing forms, verifying insurance benefits, scheduling patient calls, and liaising with specialty pharmacy teams.
Requirements
High School Diploma/GED or equivalent
Associate's degree in healthcare administration, life sciences, pharmacy technology, or a related field
Responsible for receiving verbal and written requests for prior authorization from pharmacists, physicians and/or members, supporting and assisting in the coordination of Pharmacy Services benefits.
Compensation
$44,600 - $59,745
Responsibilities
Process prior authorization requests via fax or help line by evaluating medical necessity/appropriateness
Conduct telephonic interaction with members, physician office staff, pharmacies and internal stakeholders for eligibility, coverage determination, and/or claim issues
Engage with physicians & pharmacists to conduct effective interventions through clinical therapeutic interchange
Capture accurate and comprehensive clinical information for Prior Authorization requests
Process complaints, appeals, grievances, executive inquiries and compliance related issues
Requirements
High School Diploma/GED
Nice to have: Third party prescription program claim adjudication experience
Responsible for interpreting and entering moderately complex prescriptions, processing prior authorizations, and troubleshooting adjudication issues for a pharmacy within a virtual hybrid environment.
Responsibilities
Verifies member information and inputs data for pharmacists
Educates members on pharmacy rules and medication resources
Processes prior authorization requests and ensures Medicare compliance
Provides resolution to grievances and appeals
Responds to inquiries from physicians, sales team, and members
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