Reimbursement Specialist

A Reimbursement Specialist will leverage payer, reimbursement, authorization, and referral experience and knowledge to determine patient benefits while engaging with payers telephonically or electronically. They will ensure benefit investigation outcomes are well documented and actions are taken to secure prescription prior authorization where and when necessary to get a patient on therapy. The Reimbursement Specialist will be knowledgeable of patient financial support services or assistance programs that may be offered to patients based on qualifications. Additionally, this team member will work with manager to meet the needs of the department to secure contracts, authorizations, and maximize reimbursement coverage ensuring a high quality experience for our providers and their patients when it comes to managing referrals through to service determination.

QUALIFICATION REQUIREMENTS

• 1-3 years of experience in insurance verification in a pharmacy, healthcare, or other medical setting (home infusion preferred)

• 1-3 years of experience in navigating medical and/or prescription benefits, insurance/payer requirements, and verification processes including obtaining authorizations and predeterminations from payors

• Commitment to excellent customer service and professionalism to resolve complex payer coverage issues

• Experience providing customer service to internal and external customers, including meeting quality standards for services, and evaluation of customer satisfaction.

• Electronic health medical record experience.

• Ability to multitask in a fast-paced environment.

• Basic level skill in Microsoft Office (including Word, Excel, PowerPoint, etc.).

• Willing to travel up to 5% of the time for business purposes (when necessary to attend meetings, conferences, seminars, etc.)

QUALIFICATIONS PREFERRED

• General knowledge of infusion therapy process and patient needs

• High school education or equivalent; industry experience will be considered in lieu of education. College credits or degree a plus.

• Health care experience; prefer homecare or infusion therapy experience.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Receive and translate patient referral insurance and payor information as needed to conduct outreach to patient's pharmacy or medical benefit provider/payor

• Organizes payor outreach activities in a manner most efficient to referral workflow streamlining steps to get to referral outcome where possible

• Verify current eligibility with payors on any new referral received and perform on-going verification of patient prescriptions already on service

• Properly document the outcomes of payor outreach and benefit investigation for each patient referral received in the patient electronic record

• Maintain and update authorization procedures according to the requirements of each contracted payer or as dictated by patient's insurance as determined during benefit investigation process

• Maintain and update file of all authorization forms that are insurance company specific, that are required to ensure payment Authorize on-going and new therapies provided to patients. Keep authorization current and active to ensure therapy is not disrupted for patients BioMatrix is actively managing.

• Review and determine profitability for all new patient referrals and at appropriate interval for patients on-service; work closely with leadership, clinical and/or pharmacy operations team members should other profitable options need to be considered if applicable

• Assist in developing authorization and appeal letters as necessary or required by payers for authorization approvals

• Evaluate patient's eligibility for financial assistance and initiate financial assistance process for patients as appropriate via designated channels (foundations, third party provider, internal application) as applicable to the prescription, drug/product, patient coverage for a given referral

• Create and maintain a written documentation trail for all authorization approvals, and communications with any entity that may impact reimbursement of a referral

• Work closely with Referral Specialists to convey outcomes of benefit investigation activities for further communication with patients; outcomes to include patient out of pocket costs, financial responsibility, and financial assistance options for patient support consideration

• Maintains current knowledge of BioMatrix payer contracts, in/out of network status, and reimbursement trends per product and/or pharmacy location as needed to perform reimbursement services for new referrals and existing patients

• Works collaboratively with BioMatrix Managed Markets team to share payor trends, payor-related referral outcome data, and support referral or prescription coverage escalations for active payor contracts

• Provide administrative support for all accreditation filings that entail information from the reimbursement or authorization departments.

NON-ESSENTIAL FUNCTIONS & RESPONSIBILITIES

• Ability to prioritize and handle multiple tasks and projects concurrently

• Must have scheduling flexibility and be able to work overtime (from time to time upon request)

• Careful attention to detail

• Act as a resource to other departments and participate in department meeting and office presentations with your expertise in this area of reimbursement services

• Performs related duties as requested by leadership

• Participates in quality assurance activities and audits as directed

KNOWLEDEGE, SKILLS AND ABILITIES REQUIREMENTS

• Excellent customer service and communication skills (both written and verbal)

• Working knowledge of medical terminology

• Working knowledge of reimbursement terminology,

• Ability to perform referral related work and tasks in an organized fashion with focus on complete information and time related deadlines

• Ability to complete multiple projects with time sensitive deadlines

• Ability to manage more than one priority project at a time

• Ability to work as part of a team/committee to complete assigned tasks

• Ability to exercise independent judgment and at times, work independently

• Ability to enlist cooperation of other people and department in completing assigned work and projects

• Ability to actively communicate, inspire and motivate peers, customers, and other stakeholders encountered in the referral services department

• Ability to think and act strategically and proactively

• Ability to maintain accurate records and prepare reports and correspondence related to the work

Communication Skills

• Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; demonstrates group presentation skills; actively participates in meetings.

• Written Communication - Writes clearly and informatively with professional context and direction; edits work for spelling and grammar; varies writing style to meet needs of audience; presents qualitative and quantitative data effectively; able to read and interpret written information effectively.

Computer Skills

• Become and remain proficient is all technology platforms, applications, and programs necessary to perform reimbursement specialist duties

PHYSICAL DEMANDS AND WORK ENVIRONMENT

• This position requires constant sitting with occasional walking, standing, kneeling or stooping.

• This position requires the use of hands to finger, handle or feel objects and the ability to reach with hands and arms.

• This position requires constant talking and hearing.

• Specific vision abilities required by this job include close vision and the ability to adjust focus.

• This position must occasionally lift and/or move up to 20 pounds

• Required to move/lift physical hardware.

AMERICANS WITH DISABILITY SPECIFICATIONS

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.