Benefit Investigation Specialist

Job Description:

• Responsible for direct contact with Medical Insurance Payers and Pharmacy Benefit Managers in order to identify and document available coverage options for retail and specialty medications.
• Maintains high quality customer service standards in compliance with federal and state regulations and guidelines.

Responsibilities:

• Makes outbound calls to Payers and Pharmacy Benefit Manager in order to verify patient insurance coverage and identify available Medical and Pharmacy benefits.
• Communicates case details to appropriate internal or external parties once benefit verification is complete.
• Identify any payer coverage restrictions and potential mechanisms for quickly accessing therapy.
• Ability to effectively contribute alone or in small work groups.
• Effectively meets production and time completion goals.
• Accurately document payer Prior Authorization and Appeals protocols.
• Participate in special projects and perform additional duties as required.
• Maintain repository of payer or brand specific coverage information.
• Participate in training and process improvement initiatives.

Education:

• High school diploma or equivalent, required.
• Bachelor’s degree preferred.

Experience:

• Minimum of 2 years’ experience in customer service, insurance, benefits, marketing, sales, or related area, required, or Bachelor’s degree and 1 year of relevant experience.
• Health care environment with third party benefits verification experience preferred.

Preferred Knowledge and Skills:

• Understanding of commercial insurance concepts including coverage policies, major medical benefits, knowledge of government and patient assistance program, knowledge of and understanding of how to communicate information on health insurance, reimbursements, third party terms and medical terminology is preferred.
• Ability to write routine reports and correspondence using computer applications.
• Excellent verbal skills and knowledge of medical terms.
• Ability to work efficiently in Microsoft Office, including the creation of spreadsheets in Excel and the ability to take notes via computer keyboard during telephone conversations.
• Skill in managing email correspondence and personal documentation of research.
• Focus on fundamental analytic and problem-solving skills.
• Excellent time management skills.
• Strong professional customer services experience.
• High level of attention to detail.
• Be a critical thinker who is adaptable, and results driven.