Specialist RCM - Quality Validation MM - Remote

Job Responsibilities

• Utilizes all available resources to review and verify pre-shipment information for ordered items.
• Verifies patient insurance coverage and completes a full Medical Verification of medications, administration supplies, and related pharmacy services through proper investigation into either major medical benefits or pharmacy benefits.
• Investigates prior authorization and any other claim rejections.
• Audits Major Medical claims for accuracy and document findings for quality improvement initiatives.
• Acts as subject matter expert in completing a full Medical Verification for all medications, administration of supplies and related pharmacy services and pre-shipment procedures.
• Communicates with other departments and senior managers as necessary to facilitate urgent needs.
• Enhanced review of high-risk referrals.
• Reviews patient A/R prior to completing referral audit.

Qualifications

• High school diploma from accredited school or equivalent GED.
• At least 2 years' work experience in pharmacy benefit or medical benefit insurance billing, and/or providing customer service to team members and external customers, including meeting quality standards for services, and evaluation of customer satisfaction.
• Good verbal and written communication and interpersonal skills with the ability to communicate in a diplomatic and confidential manner.
• Strong initiative with the ability to work in a team environment.
• Organized and detail oriented with proven problem solving skills.