Reimbursement Specialist

2 weeks ago


Orlando, United States RareMed Solutions Full time
Job DescriptionJob Description

Purpose:

The Reimbursement Specialist (RS) is a professional role responsible for various functions, including accurate and timely resolution to client inquiries regarding specific referral status or escalation. The RS serves as a primary point of contact for payers. The RS will manage the benefits investigation, prior authorization, and appeals process to determine patient eligibility and coverage per their plan. The RS will interact indirectly with external clients such as manufacturers and specialty pharmacies as well as internal teams including Operations and Program Management.

Responsibilities:

  • Serve as the reimbursement expert for medical and pharmacy billing on a dedicated program team.
  • Coordinate investigation and determination of patient benefits with internal program operations, insurance plans, and specialty pharmacy liaisons.
  • Apply defined business rules to qualify patients for manufacturer supported programs.
  • Work independently to complete assigned work in accordance with Standard Operating Procedures and defined service levels to complete benefits verification process, prescription coverage, and answer inquiries.
  • Use high-level problem-solving skills to research cases and resolve independently using creativity, innovation, and professional judgement to make sound decisions.
  • Maintain frequent phone contact with payers to gather all necessary information related to case/patient information, insurance coverage, and where applicable, prior authorization (PA) or appeals tracking and follow up.
  • Independently and effectively verify coverage and proactively enroll eligible patients into the commercial copay program.
  • Efficiently process patient and prescriber requests to accelerate access to therapy.
  • Serve as regional expert on payer trends, product access, and reporting reimbursement insights and/or delays, i.e., denials, underpayment, access delays.
  • Frequently communicate with program management on new insurance requirements and trends.
  • Provide concierge-level service to internal and external customers; resolve any customer and client requests in a timely and accurate manner; escalate appropriately.
  • Coordinate and collaborate with internal team members to provide reimbursement information to manufacturer representatives, HCP offices and other key personnel.
  • Strong compliance mindset, demonstrating clear understanding of patient privacy laws.
  • Active participation in building and maintaining respectful, collaborative internal/external team relationships, exercising, and encouraging positivity.
  • Other duties as assigned.

Required Qualifications:

  • High school diploma plus 2+ years recent reimbursement experience
  • Previous 2+ years of experience in a pharmacy, healthcare setting and/or pharmacy/medical insurance background
  • Advanced knowledge and experience in healthcare setting
  • Experience with benefit investigation and verification of prescription benefits
  • Ability to communicate effectively both orally and in writing with a focus on customer satisfaction
  • Ability to independently manage case load, prioritize work, and use time management skills to meet deliverables
  • Empathy, drive, and commitment to exceptional service
  • Strong analytical and organizational skills with attention to detail
  • Ability to work flexible schedule per Program business needs
  • Strong interpersonal skills


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