Pharmacy Insurance Clearance Specialist

MAJOR RESPONSIBILITIES

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. 

Data entry 

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. 

Call intake/triage 

Manages incoming and outgoing calls to complete pre-registration with patients. 

Communicates with physician and patients regarding status of authorization requests 

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.  

Benefit investigation/medication assistance 

Maintains knowledge of all stand-alone computer software programs to verify eligibility.  

Identifies and assists patients with access to internal and external financial assistance programs. 

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. 

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. 

Reauthorization processing 

Accurately collects and analyzes clinical data in support of reauthorizations 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 reauthorizations accordingly. 

MINIMUM EDUCATION AND EXPERIENCE REQUIRED

License/Registration/Certification Required: None Required. 

Pharmacy Technician certification (CPhT) issued by the Pharmacy Technician Certification Board preferred.  
 

Education Required: ​ ​High School Graduate

Experience Required: Typically requires 1 year of experience in health care, insurance industry, call center, or customer service setting.  
 

KNOWLEDGE, SKILLS, AND 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.