Reimbursement Specialist

2 weeks ago

Rome GA United States Harbin Clinic Full time

Job Summary: The Reimbursement Specialist (RS) has a primary area of expertise or experience within the reimbursement functions related oral chemotherapy agents. These functions include intake, revenue qualification, prescription-pharmacy coordination, and billing of such services. The Reimbursement Specialist is responsible for entry of information, verification of benefits, payer administrative protocols, the billing or prescriptions, and coordinating with outside pharmacies for service delivery.

Qualifications:

1. Education: High school diploma or equivalent required.

2. Experience: Previous hospital or medical experience preferably in a billing,

3. Collecting, or reimbursement position, with some clinical knowledge.

4. Ability to learn and understand pharmacy and medical benefit reimbursement issues, as well as Medicare, Medicaid, and other third party payer guidelines is required.

5. Possesses a basing understanding of medical terminology.

6. Possesses comfort and accuracy in working with computers, software such as

7. Microsoft office, and computer based pharmacy billing and electronic health records systems.

8. Ability to communicate and interface effectively with others.

9. Ability to work independently, as well as with others, to plan and organize work assignments.

10. Ability to maintain professional composure while handling stressful calls and situations.

Essential Job Functions:

11. Gathers a myriad of information from multiple sources and compiles it in a correct and comprehensive manner.

12. Processes prescriptions from medical providers.

13. Enters patient demographics, insurance information, as well as other relevant data in appropriate computer systems. Ensures information logged is accurate and entered in a timely manner.

14. Ensures all applicable staff receives communication in a timely fashion.

15. Performs comprehensive insurance verification and revenue qualification processes; authorization and re-authorization of benefits; and ensures that a source of payment, whether governmental, commercial insurance, or private pay, is available for all products and services provided.

16. Coordinates authorized products and services with clinical personnel to ensure a smooth reimbursement process and onboarding of patient to oral chemotherapy.

17. Knowledgeable of general pharmacy and medical benefit billing and reimbursement practices of commercial insurance carriers, Medicare and Medicaid. Researches and understands general billing guidelines and applies these standards appropriately.

18. Verifies the presence of necessary supplemental paperwork and/or information necessary for submitting a claim. Ensures we are compliant in our paperwork and billing practices as determined by state and federal guidelines.

19. Prepares the appropriate claim forms and transmissions in accordance with payer requirements.

20. Responsible for following-up on the status of pending prescriptions, as necessary.

21. Facilitates effective coordination of services by communicating with pharmacy, nursing, reimbursement, distribution and other staff.

22. Participates in patient/staff education and training programs as necessary.

23. Obtains referral numbers, prior authorizations, and pre-certs when necessary, and maintains log of this information.

24. Appropriately coordinates prescription information with nursing and pharmacy to ensure that documentation is in place to begin treatment.

25. Becomes proficient with the current EMR system(s) of use for communication, scheduling, and document retrieval.

26. Discusses financial information with patients regarding the prescriptions provided.

27. Works with pharmacy and other staff in obtaining any assistance funding, as necessary.

28. Communicates to all parties in a clear and understandable manner.

29. Is friendly and pleasant when dealing with others.

30. Demonstrates a thorough knowledge of all areas of responsibility and shares knowledge appropriately.

31. Exhibits effective problem solving techniques and looks for opportunities to contribute to the improvement of processes.

32. Maintains a positive and professional attitude in all situations.

33. Maintains strictest confidentiality.

34. Performs other duties as assigned.

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