Pharmacy Benefit Verification Specialist

Pharmacy Benefit Verification Specialist

Responsibilities

• Investigate, review, and load accurate patient insurances, including medical and pharmacy coverage.
• Assign coordination of benefits and run test claims to obtain a valid insurance response on patient medications.
• Investigate/identify authorization requirements needed to obtain medication coverage and enroll eligible patients in copay card assistance programs.
• Ensure accurate benefit documentation is made for all prescription orders.
• Provide thorough, accurate, and timely responses to requests from pharmacy operations, providers, and/or patients regarding benefit information.
• Perform full benefits verification on patients for pharmacy benefits and/or medical benefits utilizing electronic resources and E1 check.
• Load primary, secondary, tertiary, etc. insurances and medical insurances to patient profile.
• Run test claims at each licensed pharmacy site to obtain a valid claim response and determine optimal reimbursement.
• Document outcome of benefits review in CPR+ system to be used by operations and ensure the order is assigned to the appropriate dispensing pharmacy.
• Facilitate process for requesting medical authorizations, LOAs, and TOAs for applicable commercial, Medicaid, and Medicare, or facility medication claims.
• Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations and maintaining professional practice and patient confidentiality laws.
• Contribute to team effort by accomplishing related tasks as needed and other duties as assigned.
• Conduct job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.

Qualifications

• Education/Learning Experience: Required - High School Diploma or GED. Desired - Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician (PTCB), Specialty pharmacy experience.
• Work Experience: Required - 1+ years pharmacy or benefit verification experience. Desired - 3+ years pharmacy or benefit verification experience.
• Licenses/Certifications: Required - Pharmacy Technician License/Registration with Board of Pharmacy, as required by state law.
• Skills/Knowledge: Required - Pharmacy insurance and benefit verification, PBM and Medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, pharmacy test claim and NCPDP claim and NCPDP claim rejection resolution, coordination of benefits, NDC medication billing, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills.
• Behavior Competencies: Required - Independent worker, good interpersonal skills, excellent verbal and written communications skills, ability to work independently, work efficiently to meet deadlines and be flexible, detail-oriented, great time-management skill.