Patient Access Coordinator - Prior Authorizations (Experience with Cover-My-Meds, Prefer- Medical Assistant)
- 3200 Lake Emma Rd, Lake Mary, FL 32746, USA
Kroger Specialty Pharmacy is a Clinical Pharmacy. Our programs optimize patient outcomes by blending a high-touch, caring patient experience with specialized clinical knowledge, personalized care programs, and administrative expertise.
Perform duties to assist patients with access to benefits and co-pay cards, and schedule delivery of prescriptions provided through the specialty pharmacy, working within the limits of standard or accepted practice.
- Communicate with patients to obtain information required to process prescriptions, refills, access benefits and apply charges against co-pay cards, and build trusted and enduring customer relationships that yield loyalty.
- Investigate and verify benefits for pharmacy and medical third party claims for assigned cases. May communicate with financial assistance team of drug manufacturers to apply for and secure financial assistance for patient when assigned.
- Obtain prior authorizations; initiate requests, follow up to provide additionally required information, track progress, and expedite responses from insurance carriers and other payers, and maintain contact with customers to keep them continuously informed. Review for accuracy of prescribed treatment regimen prior to submission of authorization.
- Facilitate appeals process between the patient, physician and insurance company by requesting denial information and facilitates obtaining the denial letter from the insurance, patient or physician. Composes clinical appeals letters based off of specific denial reason and patients clinical presentation. Ensures all clinical information and documentation are obtained prior to appeal submission. Coordinates appointment of representative document with patient and physician office.
- Completes status check with insurance company regarding receipt of prior authorization and appeal and approval or denial status. Obtains approval information and activates copay cards based off of eligibility and specific drug prescribed.
- Track, report and escalate service issues arising from requests for authorizations, financial assistance or other issues that delay service, to ensure patient access and to avoid delays that may interrupt therapy.
- Build and maintain effective business relationships with prescribers treating assigned set of disease states, and provide ongoing communication of specific case-related information as appropriate.
- Completes a series of assessments mandated by either manufacturer contracts or operations and facilitates patient enrollment with manufacturer Hubs when required.
- Document case activity, communications and correspondence in computer system to ensure completeness and accuracy of patient contact records. Ensure that work activities are conducted in compliance with regulatory requirements and the organization’s defined standards and procedures, and in a manner that provides the best available level of service and quality.
- Perform or assist with any operations, as required to maintain workflow and to meet schedules and quality requirements.
- Participate in any variety of meetings and work groups to integrate activities, communicate issues, obtain approvals, resolve problems and maintain specified level of knowledge pertaining to new developments, requirements, and policies.
- Perform other related duties as assigned.
- Superior telephone customer service skills with the ability to build effective, appropriate and enduring customer and provider relationships.
- Strong organization and case administration skills as well as attention to detail.
- Excellent knowledge of insurance benefit investigation process and techniques.
- Demonstrated case ownership orientation with the ability to manage a range of priorities and meet time commitments.
- Excellent Microsoft Office and data management software skills with demonstrated adaptability to internal systems (CPR+).
- Demonstrated strength in listening, oral and written communications in English.
- High School Diploma or equivalent required. Some college preferred.
- Additional specialized training in pharmacy/medical benefit access and requirements highly preferred.
- Minimum 1 year’ proven work experience in a healthcare or customer service industry.
- Healthcare experience with a basic understanding of clinical terms and benefits investigation preferred.
- Previous experience in a call center preferred where there is familiarity with metrics and a high level of accuracy and touches.
- Some jurisdictions where this role is performed may require that associates maintain endorsement as a Certified Pharmacy Technician and report through a Pharmacist, in addition to the above requirements.
All your information will be kept confidential according to EEO guidelines.