Job Description

Employment Type:

Full time

Shift:

Description:

The Specialty Pharmacy Revenue Cycle Specialist is responsible for performing the appropriate processes to obtain and verify patient insurance eligibility and benefits, prior authorizations as needed, schedule delivery of patient medication and collect patient co-pays. Other responsibilities include major medical billing, third party collections with follow-up, and reporting.

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

Performs investigation of benefits and eligibility by phone and/or internet to determine coverage choices the patient has to start therapy.

Answers questions and provides information to patients and providers as it pertains to the patient's pharmacy benefits.

Determines if prior authorization is needed for the claim to be paid.

Gathers appropriate documentation, completes necessary forms, and submits authorization requests.

Collaborates with Clinical Staff to ensure appropriateness of the prior authorization documentation and ensures completeness of the prior authorization questionnaires.

Collaborates with Integrated Specialty Pharmacy Staff located in the Physician Practice in support of activities including but not limited to benefits investigation, prior authorization request and submission, overturning appeals, and enrolling patient in financial assistance programs.

Manages the prescription referrals in a progressive order to ensure all new patients and providers receive communication within the timeframe stated in the policy and procedure.

Escalates service issues arising from prior authorization request or other issues that delay service, to ensure patient access and to avoid delays that may interrupt therapy.

Communicates with the provider updating them on the continual status of the patient's prescription order.

Documents all activities in the appropriate system for each contact made to the patient, provider, and insurance plan.

Facilitates appeals process between the patient, physician, and insurance company by requesting denial information. Facilitates obtaining the denial letter from the insurance, patient, or physician.

Collaborates with clinical staff to ensure all required information and documentation are obtained prior to appeal submission.

Participates in quality improvement activities.

Triages all clinical calls to clinical staff.

Contacts patients to schedule the delivery of their medication and collect patient copays at the time of scheduling.

Submit Medicare B claims

Submit Major Medical claims (primary and secondary) as needed through the appropriate billing system

Performs third party collection activities on outstanding unpaid claims and document such activities as they occur.

Follow up on all patient and third-party collection activities as needed.

Complies with all regulatory requirements, including HIPAA/HITECH.

Performs other duties as needed and assigned by the manager.

Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

MINIMUM QUALIFICATIONS

1. Must possess a comprehensive knowledge of adjudicating prescription drug claims as normally obtained through experience working in a specialty, home infusion, hospital, or retail pharmacy preferred.

2. Experience with adjudicating prescription claims, corresponding with insurance companies and processing payments, strongly preferred.

3. Familiarity with specialty pharmacy products and operations preferred.

4. Knowledge of home infusion, mail order pharmacy or general pharmacy operations is preferred.

5. Knowledge of Microsoft office products, including Word, Excel, PowerPoint and other graphics or presentation software.

6. Must understand how to interpret an Explanation of Benefits.

7. Understands how to request vacation/lost/damage overrides from the insurance carriers when warranted.

8. Experience with billing Medicare B and other major medical commercial insurance billing using HCPCS J-codes preferred.

9. Knowledge of posting denials and processing payments from both third-party insurance companies and patients, as well as keeping a detailed record of said denials and payments in the appropriate accounts receivable system

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran

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