POSITION SUMMARY
The primary purpose of this position is to process third party claims (billing and collection) on-line to pharmacy insurance carriers for the cost of pharmaceuticals furnished to patients who are covered by health insurance policies and have received treatment at the facility. Also, provides claim processing for non-beneficiaries who receive medical services at the facility.
ESSENTIAL FUNCTIONS:
- Receives the pharmacy prescription dispensing reports electronically via on-line billing system. Determines if the prescription written by the provider is billable as defined by insurance guidelines. Verifies prescription amount dispensed for reimbursement by Pharmacy.
- Requests and obtains prior authorization for various pharmaceutical products from insurance companies. Receives and completes authorization forms providing all data required, obtains signatures, and returns as needed for processing of collection.
- Resolves problems associated with on-line billing. Researches and follows-up on rejected claims on-line in order to ensure maximum reimbursement to the facility, includes telephone contacts and any steps necessary for satisfactory resolution of the claim.
- Ensures pharmaceuticals are billed according to Dispense-As-Written (DAW), Drug Utilization Review, Dosaging, and Payer Format (BIN #) guidelines. Manages and reconcile rejects through interpreting clinical messages, DUR specification codes, and appending/amending claims for payment.
- Comprehends terminology for pharmaceutical products and correlate medical and clinical procedures and services provided by the facility against terms of the policies.
- Prepares end of month and quarterly status reports that list amounts billed, collected and not collected.
- Works rotational shift; Sunday through Saturday.
- Performs other duties as assigned.
MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Physical:
The work is primarily sedentary with the following physical requirements: ability to lift up to 25 pounds, walk for short periods of time and sit for long periods of time, ability to stoop and pick up objects from the floor without restrictions, and have full use of hands and arms, i.e., to operate office equipment such as computer, calculator, printer, fax, etc.
Exercises initiative and judgment in deviating from existing department or corporation practices to resolve billing issues/concerns. Work is reviewed for conformance to policies, procedures, and practices relating to billing practices.
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