Pharmacy Insurance Clearance

Pharmacy Insurance Clearance

Requirements

• High School Graduate
• Typically requires 1 year of experience in health care, insurance industry, call center, or customer service setting
• Pharmacy Technician certification (CPhT) issued by the Pharmacy Technician Certification Board preferred
• Demonstrate ability to identify and understand issues and problems
• Ability to problem solve in a high profile and high stress area
• Mathematical aptitude, effective communication, and critical thinking skills
• Ability to prioritize and organize workload
• Excellent verbal and written communication skills
• Knowledge of medical terminology
• Demonstrated technical proficiency including experience with insurance authorization/eligibility tools, EPIC, Microsoft Office, Internet browser and telephony systems

Responsibilities

• Participates in department staff meetings and keeps abreast of continuing education to ensure effective communication and to maintain skill competency
• Attends all mandatory in-services 100% and completes all mandatory safety in-services and skill competencies as required
• Seeks out education opportunities to increase knowledge in department procedures and actively participates in group projects to problem solve departmental improvement opportunities
• Data entry
• Pre-registers and registers patients using established procedures for computer entry for all ancillary and nursing units, keeping current with the specialized needs, preparing necessary documents/records and patient education when necessary
• Ensures accurate entry of patient demographic and insurance information in the ADT system with special attention to carrier code assignment, complete benefit, eligibility record and authorization data
• Manages incoming and outgoing calls to complete pre-registration with patients
• Communicates with physician and patients regarding status of authorization requests
• Ensures completion of all established policies and procedures for identification and notification of the Primary Care Physician in the case of HMO coverage
• Coordinates with patient and provider to ensure patient can select the most cost-effective options based on insurance benefits
• Maintains knowledge of all stand-alone computer software programs to verify eligibility
• Identifies and assists patients with access to internal and external financial assistance programs
• Initiates communication to the patient when authorization is not obtained, or services are not covered, and explains the potential financial responsibility
• Coordinates with patient, clinical team, and assistance programs to secure reimbursement or alternative coverage options when requested services are at financial risk
• Identifies at risk balances related to Medicaid eligibility rules and communicates to Financial Counseling, UM, and physicians
• Educates uninsured patients of financial responsibilities
• Refers patient for assessment of additional insurance coverage and internal charity programs
• Coordinates with patient and provider teams to complete applications for external program assistance
• Accurately collects and analyzes clinical data in support of reauthorizations for inpatient and outpatient services required by the payor guidelines, ensuring chart documentation supports coverage of services, payor facility/provider guidelines are followed and submits reauthorizations accordingly

Preferred Qualifications

• Pharmacy Technician certification (CPhT) issued by the Pharmacy Technician Certification Board preferred