BENEFIT COORDINATOR

Description

JOB SUMMARY: The Benefit Coordinator is responsible to verify the coverage criteria for all injectable and infusion drugs as well as run monthly/quarterly reports on said injectable and infusion drugs to ensure reimbursement is above the providers cost. Distributes and reviews drug reports with the providers. Works closely with the Pharmacy in monitoring the drug charges for potential increases as well as new drugs that a provider wants to purchase/provide by researching insurance carriers medical and administrative policies. Responsible to respond to all Medicare and Medicaid medical record requests and reporting requests/outcomes to the Corporate Compliance Committee. Assists in preparing yearly Medicare update memo and presents at Corporate Compliance. Assists patients with obtaining grants for out of pocket costs related to injectable and infusion drugs. Responsible to verify benefits and research the medical and/or administrative policies for procedures performed by the providers, such as but not limited to, PM&R, Plastic/Reconstructive, and Orthopedics. Will research medical and administrative policies for all new services that current or new providers may express interest in (Performa).

Duties & Responsibilities

• Will receive via in basket or fax all injectable and infusion drug benefit requests from the provider offices. Responsible to verify coverage benefits by reviewing the medical and/or administrative policies, as well as authorization requirements, and notifying provider offices accordingly via in basket.
• Responsible to educate provider offices of injectable and infusion drug medical and administrative policies.
• Responsible to work with the Information Technology to obtain monthly/quarterly injectable and infusion drug reports. Is responsible to review all injectable and infusion drug reimbursements (by obtaining the drug cost from the Pharmacy) to ensure the provider is being reimbursed above their cost per policy and procedure. Will review each report with the applicable provider.
• Responsible to work directly with the Pharmacy in monitoring injectable and infusion drugs for recommended charge increases as well as researching the coverage criteria when providers would like to order new drugs.
• Responsible to ensure all injectable and infusion drug denials are reviewed and fully worked to ensure full payment.
• Responsible to assist patients with obtaining grants/co-pay assistance for out of pocket costs related to injectable and infusion drugs.
• Responsible to respond to all Medicare and Medicaid medical record requests and reporting requests/outcomes at the Corporate Compliance Committee.
• Responsible to work with Information Technology to obtain monthly injectable and infusion drug reimbursement reports for Medicaid and Workers’ Compensation/No Fault to ensure the charges were billed at the acquisition cost per policy and procedure.
• Will attend all Business Office meetings and assist with training as needed. For example, sending memos, reviewing with other departments, etc.
• Responsible to prepare yearly Medicare update memo and present at the Corporate Compliance Committee.
• Responsible to stay abreast of all Medicare and Medicaid updates as well as infusion/injectable coverage guidelines for all other insurances.
• Responsible to train applicable support staff to complete injectable and infusion drug benefit requests while out of the office. Will ensure competency of support staff by auditing completed benefit requests as well as keeping reference materials up to date.
• Will utilize the electronic work queue for all benefit quotes, adding patient accounts and completing the account per policy.
• Responsible to verify benefits and research medical and/or administrative policies for procedures performed by the providers. Will provide to and review said policies with the providers.
• Will participate in any future development of new services that current or future providers may want to provide by researching all medical and administrative policies applicable to said service.
• Other duties as assigned.
• May be exposed to hazardous drugs.
• Attends OSHA training upon initial employee orientation and annually completes OSHA competency.
  
  

Requirements

RELATIONSHIP WITH OTHERS: Must work effectively with fellow team members, Business office staff as well as insurance companies. Will work directly with other departments such as Clinical, Pharmacy, Contracting, Data, as well as Providers.

EDUCATION/EXPERIENCE/KNOWLEDGE: Graduated from High School or completed GED requirements. EMR and insurance knowledge preferred. Skilled in Microsoft products including word and excel.

PHYSICAL REQUIREMENTS: Requires sitting, standing bending and reaching. May require lifting up to 20 pounds. Requires manual dexterity sufficient to operate standard office equipment such as computer, fax, calculators and telephone. Requires normal hearing and vision.