Remote Claims Processor Jobs in Belle, WV (NOW HIRING)

Location:

Pay Range:

Primary Key Performance Areas:

KPA 1 - Insurance Verification

• Verify Private, Medicaid, and Medicare insurance coverages (include VA, IHS, and other unique programs).

• Complete patient facility (Hospital, Hospice, Rehab, ALF, Skilled Nursing, etc.) verifications and determine medication coverage.

• Verify patient eligibility to utilize AON Pharmacy via test claim to their pharmacy insurance.

• Refers prescriptions to our Prior Authorization or Financial Assistance teams based on test claim responses.

• Offer and enroll patients in manufacture copay cards for commercial payors to assist in covering patient financial responsibility.

KPA 2 - Specialty Pharmacy Referrals

• Determine network coverage for specialty oncology and hematology medications.

• Determine which pharmacy can dispense on behalf of the patient.

• Inform patients of prescription referral to outside pharmacies and notify nursing staff to forward prescription.

• Document prescription referrals in the EMR system to alert physicians and clinic staff of the appropriate dispensing pharmacy.

KPA 3 - Claims Resolution

• Obtain Limited Distribution Overrides for AON Pharmacy to fill.

• Understand claim responses regarding patient plan structure and educate patients regarding financial responsibility.

• Resolves COB coverage issues with patients and payor to correctly adjudicate claims.

• Resolve any claim submission issues with outside dispensing pharmacies that are outside the scope of the Intake team.

KPA 4 - Pharmacy Call Center Communication

• Ensure effective communication and premier customer service with all internal and external customers.

• Demonstrate the ability to actively listen and understand patient questions and provide accurate answers and solutions. Will ensure that all phone calls are addressed professionally, courteously and in a timely manner.

• Act as a liaison between teams to communicate changes and help improve interdepartmental processes to improve patient care.

• Review incoming team emails to verify they are answered in a timely and professional manner.

KPA 5 - Compliance

Ensure all local, state, and federal guidelines are followed as well as corporate policies, pharmacy Standard Operating Procedures (SOPs) and accreditation bureaus' standards.

Examples of job duties include, but not limited to:

• Verify all department compliance training is completed by the established deadlines.

• Maintain continuing education requirements for licensure.

• Maintain and ensure the confidentiality of all patient and employee information as required by the HIPAA regulations. Will assist department management in ensuring the storage, collection, and destruction of all Protected Healthcare Information is adherent to all federal and state guidelines, in addition to all accreditation standards.

• Performs other duties and projects as assigned

Education: High school education, GED, or equivalent required

Certifications/Licenses: Active/Unrestrictive Pharmacy Technician permit in the state of residence. Willing to obtain Florida Technician permit (if applicable).

Previous Experience: Two years' experience in specialty, retail, mail order, or hospital pharmacy as a pharmacy technician is required.

Core Capabilities:

• Analysis & Critical Thinking: Critical thinking skills including solid problem solving, analysis, decision-making, planning, time management and organizational skills. Must be detail oriented with the ability to exercise independent judgment.

• Interpersonal Effectiveness: Developed interpersonal skills, emotional intelligence, diplomacy, tact, conflict management, delegation skills, and diversity awareness. Ability to work effectively with sensitive and confidential material and sometimes emotionally charged matters.

• Communication Skills: Good command of the English language. Second language is an asset but not required. Effective communication skills (oral, written, presentation), is an active listener, and effectively provides balanced feedback.

• Customer Service & Organizational Awareness: Strong customer focus. Ability to build an engaging culture of quality, performance effectiveness and operational excellence through best practices, strong business and political acumen, collaboration and partnerships, as well as positive employee, physician and community relations.

• Self-Management: Effectively manages own time, conflicting priorities, self, stress, and professional development. Self-motivated and self-starter with ability to work independently with limited supervision. Ability to work remotely effectively as required.

• Must be able to work effectively in a fast-paced, multi-site environment with demonstrated ability to juggle competing priorities and demands from a variety of stakeholders and sites.

• Computer Skills:

  • Proficiency in MS Office Word, Excel, Power Point, and Outlook required.

• Travel: 0% <25%

• Standard Core Workdays/Hours: Monday to Friday 8:30 AM - 5:00 PM local residence time.

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