Pharmacy Insurance Clearance Specialist

Major Responsibilities:

• Accurately collects and analyzes clinical data in support of insurance authorizations for inpatient and outpatient services required by the payor guidelines, ensuring chart documentation supports coverage of services, payor facility/provider guidelines are followed and submits authorization accordingly. Uses resources to determine appropriate procedure codes for authorization to ensure appropriate reimbursement.
• Acquires and maintains current knowledge of all insurance requirements as it relates to patient/hospital responsibility for authorizations and hospital billing, including all Federal and State regulations. Manages workload to ensure timeliness of authorization requests and communicates with physician and patients regarding status. Partners with clinical team to understand urgency of treatment to ensure prompt turnaround times.
• Maintains knowledge of all stand-alone computer software programs to verify eligibility and authorization.
• Initiates communication to the patient when authorization is not obtained, or services are not covered, and explains the potential financial responsibility. Coordinates with patient, clinical team, and assistance programs to secure reimbursement or alternative coverage options when requested services are at financial risk. Identifies at risk balances related to Medicaid eligibility rules and communicates to Financial Counseling, UM, and physicians.
• Ensures completion of all established policies and procedures for identification and notification of the Primary Care Physician in the case of HMO coverage. Coordinates with patient and provider to ensure patient can select the most cost-effective options based on insurance benefits. Identifies and assist patients with access to internal and external financial assistance programs.
• Educates uninsured patients of financial responsibilities. Refers patient for assessment of additional insurance coverage and internal charity programs. Coordinates with patient and provider teams to complete applications for external program assistance.
• Acts as internal resource to identify coverage criteria for high cost services. Partners with clinical teams to ensure the insurances’ preferred products/services are ordered to reduce denials and delays in treatments. Knowledge in multiple Advocate Aurora service areas and partnerships to ensure integrated services are provided when applicable.
• Determine when procedures have high risk of claim denial and submits medical necessity reviews with insurance prior to treatment, when available. When insurance does not allow pre-claim review, partners with providers to ensure chart documentation has supporting documentation based on industry guidelines. Partners with post service teams to ensure appropriate documents are submitted for claim review. Notifies providers and patient of prior authorization denials and manages submission of appeals to insurance.
• Manages incoming and outgoing calls to complete pre-registration with patients. Pre-registers and registers patients using established procedures for computer entry for all ancillary and nursing units, keeping current with the specialized needs, preparing necessary documents/records and patient education when necessary. Ensures accurate entry of patient demographic and insurance information in the ADT system with special attention to carrier code assignment, complete benefit, eligibility record and authorization data.
• Participates in department staff meetings and keeps abreast of continuing education to ensure effective communication and to maintain skill competency. Attends all mandatory in-services 100% and completes all mandatory safety in-services and skill competencies as required. Seeks out education opportunities to increase knowledge in department procedures and actively participates in group projects to problem solve departmental improvement opportunities.

Licensure, Registration, and/or Certification Required:

• Certified Pharmacy Technician preferred.

Education Required:

• High School Graduate.

Experience Required:

• Typically requires 3 years of experience in health care, insurance industry, call center, or customer service setting.

Knowledge, Skills & Abilities Required:

• Demonstrate ability to identify and understand issues and problems. Examines data and draws logical conclusions based on information available.
• Ability to problem solve in a high profile and high stress area.
• Mathematical aptitude, effective communication, and critical thinking skills.
• Ability to prioritize and organize workload.
• Excellent verbal and written communication skills.
• Knowledge of medical terminology.
• Demonstrated technical proficiency including experience with insurance authorization/eligibility tools, EPIC, Microsoft Office, Internet browser and telephony systems.

Physical Requirements and Working Conditions:

• Must be able to sit most of the workday.
• May include intermittent light travel.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.