Major Responsibilities:
- Obtains insurance and patient information, applying acquired knowledge of government and third party payer requirements to assist in the referral source and pharmacy clinicians in determining coverage for infusion and enteral services and to justify payment of pharmacy drug claims.
- Contacts third party payers to obtain authorizations for pharmacy services. Follows up with referral source, pharmacy clinicians, patients and third party payers to complete the prerequisite information and to secure physician referrals.
- Partners with other departments, providers/physicians, third party payers and government representatives for the purpose if identifying any potential out-of-pocket expenses for the patient and to make mutually satisfactory payment.
- Registers patients, obtains and updates demographic and insurance information, verifies insurance coverage to ensure accurate claims are generated.
- Reviews ordered therapy and applies payer rules to correctly generate Assignment of Benefit and Advanced Beneficiary Notification forms.
- Educates patients, staff, pharmacy clinicians and providers regarding referral and authorization requirements, payer coverage, eligibility guidelines, documentation requirements and insurance changes or trends.
- Collaborates with case managers to ensure accurate, timely and complete information is forwarded to accounts receivable. Notifies patient accounts staff of insurance coverage lapses, benefit information and self-pay status.
- Maintains files for referral and insurance information and a list of current accepted insurance. Maintains knowledge of and reference materials of Medicare, Medicaid and third-party payer requirements, guidelines and policies. Remains up-to-date on insurance plans requiring pre-authorization.
Licensure, Registration, and/or Certification Required:
Education Required:
Experience Required:
- Typically requires 5 years of experience in the home infusion industry or in accounts receivable, that includes experiences in third party payer plans and requirements (authorization, referral and pre-certification), medical processes and workflow, and customer service.
Knowledge, Skills & Abilities Required:
- Understanding of medical terminology and procedures for application in the patient referral / pre-certification / authorization process.
- Working knowledge of Medicare/Medicaid Home Health reimbursement guidelines preferred
- Strong analytical, prioritization and organizational skills.
- Ability to work independently with minimal supervision.
- Detail oriented with the ability to multi-task.
- Exceptional communication and interpersonal skills with a high degree of diplomacy and tact. Ability to effectively communicate with a variety of people under stressful situations.
- Strong computer skills including experience in using Microsoft Office applications or similar products and electronic medical record systems.
Physical Requirements and Working Conditions:
- Exposed to a normal office environment.
- Must be able to sit, stand and walk through out the work day.
- Must be able to lift up to 10 lbs. occasionally.
- Must be able to speak clearly and hear to communicate with people in person or over the telephone and to hear a voice page system.
- Operates all equipment necessary to perform the job.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
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