Reimbursement Specialist

From Intake to Outcomes, CareMetx is dedicated to supporting the patient journey by providing hub services, innovative technology, and decision-making data to pharmaceutical, biotechnology, and medical device innovators.

Job Title: Reimbursement Specialist

POSITION SUMMARY:

Under the general supervision of the operational program leadership, the Reimbursement Specialist is responsible for various reimbursement functions, including but not limited to benefit investigations, prior authorization support, and call triage. The Reimbursement Specialist responds to all provider account inquiries, appropriately documents all provider, payer and client interactions into the CareMetx Connect system and ensures that the necessary data for prior authorization request are obtained.

PRIMARY DUTIES AND RESPONSIBILITIES:

• Collects and reviews all patient insurance benefit information, to the degree authorized by the SOP of the program.
• Provides assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications.
• Completes and submits all necessary insurance forms in a timely manner as required by all third party payors for prior authorizations. Tracks and follow up on prior authorization request.
• Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
• Maintains frequent phone contact with provider representatives, third party customer service representatives, and pharmacy staff.
• Reports any reimbursement trends/delays to supervisor.
• Processes any necessary insurance/patient correspondence.
• Provides all necessary documentation required to expedite prior authorization request. This includes demographic, authorization/referrals, National Provider Identification (NPI) number, and referring physicians.
• Coordinates with inter-departmental associates as necessary.
• Communicates effectively to payors to ensure accurate and timely benefit investigations.
• Works on problems of moderate scope where analysis of data requires a review of a variety of factors. Exercises judgment within defined standard operating procedures to determine appropriate action.
• Reports all Adverse Events (AE) disclosed in alignment with training and Standard Operational Procedures (SOP)
• Typically receives little instruction on day-to-day work, general instructions on new assignments.
• Other duties as assigned - Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

Qualifications

EXPERIENCE AND EDUCATIONAL REQUIREMENTS:

• High School, Diploma, or GED required
• Previous 1+ years of experience in a specialty pharmacy, medical insurance, physician’s office, healthcare setting, and/or related experience.

MINIMUM SKILLS, KNOWLEDGE AND ABILITY REQUIREMENTS:

• Ability to communicate effectively both orally and in writing.
• Ability to build productive internal/external working relationships.
• Strong interpersonal skills.
• Strong negotiating skills.
• Strong organizational skills; attention to detail.
• General knowledge of pharmacy benefits, and medical benefits.
• Global understanding of commercial and government payers preferred.
•  Ability to proficiently use Microsoft Excel, Outlook and Word.
•  Ability and initiative to work independently or as a team member.
•  Ability to problem solve.
•  Strong time management skills.
•  Customer satisfaction focused.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

•         While performing the duties of this job, the employee is regularly required to sit.
•         The employee must occasionally lift and/or move up to 10 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Schedule

• Must be flexible on schedule and hours 
• Overtime may be required from time to time
• Must be willing to work weekends if required to meet company demands

CareMetx considers equivalent combinations of experience and education for most jobs. All candidates who believe they possess equivalent experience and education are encouraged to apply.

At CareMetx we work hard, we believe in what we do, and we want to be a company that does right by our employees. Our niche industry is an integral player in getting specialty products and devices to the patients who need them by managing reimbursements for those products, identifying alternative funding when insurers do not pay, and providing clinical services.

CareMetx is an equal employment opportunity employer. All qualified applicants will receive consideration for employment and will not be discriminated against based on race, color, sex, sexual orientation, gender identity, religion, disability, age, genetic information, veteran status, ancestry, or national or ethnic origin.