Pharmacy Benefit Verification Specialist

Pharmacy Benefit Verification Summary

The Benefit Verification Specialist will investigate, review, and load accurate patient insurances, including medical and pharmacy coverage, assign coordination of benefits, 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. They will ensure accurate benefit documentation is made for all prescription orders.

Major Responsibilities

• Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.
• Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding benefit information.
• Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information.
• Performs full benefits verification on patients for pharmacy benefits and/or medical benefit utilizing electronic resources and E1 check to 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, then 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 compliance with professional practice and patient confidentiality laws.
• Contributes to team effort by accomplishing related tasks as needed and other duties as assigned.

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.

Skills/Knowledge

• Pharmacy insurance and benefit verification
• PBM and Medical contracts
• Knowledge/understanding of Medicare, Medicaid, and commercial insurance
• Pharmacy test 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

• 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