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 pharmacy claim processing for non-beneficiaries who receive medical services at the facility.
ESSENTIAL FUNCTIONS:
- Attempt to collect any self-payment(s)/copayment(s) amount owed by non-beneficiary patient at point of sale or via reporting.
- Ensure open professional communication to Patient Registration, Pharmacies, Patient Benefit Coordinators, Prior Authorization Team, Patient Access Specialists, Accounting Technicians, TPMS and 3rd Party Help Desk.
- Receive the pharmacy prescription dispensing reports electronically via on-line billing system. Determine if the prescription written by the provider is billable as defined by insurance guidelines. Verify prescription amount dispensed for reimbursement by Pharmacy.
- Familiar with Prescription Insurances; Medicaid, Medicare, Part D and Commercial Plans.
- Request and obtain prior authorization for various pharmaceutical products from insurance companies. Receive and complete authorization forms providing all data required, obtains signatures, and returns as needed for processing of collection.
- Resolve problems associated with on-line billing. Research and follow-up on rejected claims on-line in order to ensure maximum reimbursement to the facility, including telephone contacts and any steps necessary for satisfactory resolution of the claim.
- Ensure pharmaceuticals are billed according to Dispense-As-Written (DAW), Drug Utilization Review, Dosaging, and Payer Format (BIN #) guidelines. Manage and reconcile rejects through interpreting clinical messages, DUR specification codes, and appending/amending claims for payment.
- Comprehend terminology for pharmaceutical products and correlate medical and clinical procedures and services provided by the facility against terms of the policies.
- Ability to use system applications to operate daily pharmacy production.
- Manage A/R Reports, In-House rejection, denial reports and audit reconciliation of all transactions/scripts.
- Prepare end of the month and quarterly status reports that list amounts billed, collected and not collected.
- Work rotational shift, Sunday through Saturday, as scheduled.
- Ensure proper PPE is worn at all times while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.
- Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updates)
- Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer satisfaction.
- Performs other duties as assigned.
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 10 pounds, walk for short periods of time, sit for long periods of time, stoop and pick up objects from the floor without restrictions, have full use of hands and arms for simple/firm grasping, fine manipulation, and use of keyboards, i.e., to operate office equipment such as computer, calculator, printer, fax, etc. Must have the ability for prolonged use of near vision, color vision, depth perception, seeing in fine details, hearing normal speech, hearing overhead pages over a loudspeaker, and utilize a telephone. May occasionally need to use far vision.
Mental:
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. Must have prolonged ability to cope with high level of stress; make decisions under high pressure; cope with anger/fear/hostility of others in a calm way; manage altercations; concentrate; handle high degree of flexibility; handle multiple priorities in stressful situation; demonstrate high degree of patience; adapt to shift work; and, work in areas that are close and crowded. May frequently need to work alone.
Environmental:
May occasionally be exposed to infectious disease, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises.
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NECESSARY QUALIFICATIONS
Education:
High School Diploma or GED
Experience:
Minimum of one (1) year experience related to pharmaceutical terminology, billing, or general pharmacy operations
Other Skills and Abilities:
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:
- Positive working relationships with others
- Possession of high ethical standards and no history of complaints
- Reliable and dependable; reports to work as scheduled without excessive absences.
- Working effectively in team relationships
- Completion of and, above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job
- Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
- Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
- Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading, or incomplete information, as determined by TCRHCC
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