Pharmacy Claims Specialist Job at Southern Pharmacy Services Winston-Salem
Kernersville, North Carolina, United States of America
Southern Pharmacy Services is part of the Guardian Pharmacy Services network and prides itself on its customer service. Each team member plays an integral part in the success of the pharmacy.
Schedule: Full Time, Monday-Friday 10:00am-7:00pm, with a weekend rotation.
This role will be performed onsite at our closed-door pharmacy in Kernersville, NC. All patient interactions will be over the phone.
We Offer:
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Comprehensive training provided side by side with training team.
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Must be comfortable working in a high-volume environment.
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We offer full time benefits including health, vision, dental and matching 401k options.
Under the direction of the Director, process claims to insurance companies and all billing related processes and provide excellent customer service and care to patients, caregivers, and medical providers. May assist in the process of claim adjudication from 3rd party insurances.
Attributes Required:
Essential Job Functions (include the following):
Education and/or Certifications:
Skills and Qualifications:
Work Environment:
Attributes Required:
- Work Ethic/Integrity – must possess intrinsic drive to excel coupled with values in line with company philosophy
- Relational – ability to build relationships with business unit management and become “trusted advisor”
- Strategy and Planning – ability to think ahead, plan and manage time efficiently
- Problem Solving – ability to analyze causes and solve problems at both a strategic and functional level
- Team Oriented – ability to work effectively and collaboratively with all team members
Essential Job Functions (include the following):
- Provide staff support for claims processing, payer compliance requirements and related prescription documentation processes including prior authorizations
- Verify patient eligibility, prescription benefits, input insurance into the system or look up missing insurance information and preparation and submission of claims to insurance companies; commercial, Medicare, Medicaid and other third-party payers
- Continually audit patient files and maintain corresponding documentation necessary to defend third party audits and maintain payer and company compliance
- Review and prepare facility and patient statements monthly, review reimbursement reports, pursue payment from delinquent accounts, arrange payment arrangements and collection accounts
- Assist patients, caregivers, and related providers with questions regarding insurance eligibility, coverage, related benefits, and payments
- Process and reconcile third party reimbursements, EOBs, patient payments, returns, and credits
- Transmit individual credit card payments as needed
- Process returns and appropriately return stock to ensure accuracy
- Logging insurance fees into the system
- Run script management
- Review and run rejection reports and process accordingly
- Audit research
- Answer phone calls related to billing questions
- May require cross training in other areas of the pharmacy
- Other essential functions and duties may be assigned as needed
- Reprocess rejected claims to 3rd party providers by identifying why the claim was rejected and making any necessary corrections (prior authorization, new ID#, etc.)
- Complete prior authorization request forms
- Processing medication change requests, faxing them to facilities, and tracking outcome.
- Make outgoing calls to insurers, responsible parties and others to follow up on rejected claims and to garner accurate insurance information.
Education and/or Certifications:
- High School Diploma or GED required; Associates Degree preferred
- Pharmacy Technician license/certification/registration (per state requirements); National Certification preferred (PTCB) may be required (pharmacy specific).
Skills and Qualifications:
- 1+ years of customer service experience required
- 1+ years of related experience (advanced degree may substitute for experience) preferred
- Advanced computer skills; pharmacy operations system experience preferred/required
- Ability to work independently and deliver to deadlines
- Ability to solve problems with minimal direction
- Great attention to detail and accuracy
- Ability to excel in a fast-paced, team-oriented environment working on multiple tasks simultaneously, while adhering to strict deadlines
- Quality minded; motivated to seek out errors and inquire when something appears inaccurate
- Long term care or retail pharmacy technician or billing experience preferred, but not required
Work Environment:
- Ability to work flexible hours
Full-Time employees working 30+ hours per week are eligible to enroll in our comprehensive benefits package, which includes medical, dental, vision, short and long-term disability, life and supplemental life insurance, and PTO.
All employees are eligible to enroll in our company matched 401(k) plan.
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