Regular
Non-Exempt
GENERAL DESCRIPTION:
Administrative work that involves receiving service/follow-up requests by phone or fax, monitoring, evaluating, and channeling service/follow-up requests received for all business lines. Makes evaluations based on the guides and compliance criteria to authorize services of determinations and organizational appeals. Makes data entry related to the request processing in the various existing electronic applications.
ESSENTIAL FUNCTIONS:
Receive medication-related requests by medical and pharmacy components for coverage and organizational determinations and appeals via facsimile and channel them as appropriate for both lines of business.
Analyzes requests, including medical orders, to identify the type of service requested and channels them to the corresponding agents.
Performs data entry of events in the corresponding system and documents the demographic and clinical information (medical order) pertinent to the patient requesting the service.
Verifies the request (medical order) to verify the following: Complete prescription, legible with all its parts: date, medical signature, licenses, eligibility, benefit coverage, identify benefit limitations/exclusions, and identify the provider (pharmacy or doctor) and the appropriate setting for the required service.
Channels requests that require authorization based on medical necessity to the pharmacy technician or the corresponding person for review and determination.
Answers the calls received in the department, directs them to the corresponding programs, and ensures compliance with the privacy policy during the handling of information.
Attends pre-authorization status requests that are received from authorized persons, ensuring compliance with HIPAA regulations.
Notifies the insured party or provider of the pre-authorization number assigned to the requested service.
Manages the electronic application for receiving facsimiles and electronically distributes received documents to pharmacy technicians as appropriate.
Ensures the proper distribution and channeling of cases incorrectly referred to a department.
Complies with the standards established in the Company related to service, compliance, and quality in each process inherent to their position.
Provides support to clinical staff in administrative tasks, such as making calls to providers and patients, photocopying, scanning, and filing documents, etc.
Updates the statistics and reports measuring the results of the work, which will be presented to the management, as requested. This is done to report the results of event referrals, faxes, and requests that were received and distributed based on the standards established by the business line.
Receives and manages the Determination case file request with the PBM. Initially evaluates, organizes, and distributes Pharmacy Commercial Appeals (PPACA) requests in accordance with the established requirements.
Complies fully and consistently with Company standards, policies, and procedures in conjunction with local and federal laws applicable to the industry, business, and employment practices.
May perform other duties and responsibilities (if assigned) in accordance with the education and experience requirements stipulated in this document.
MINIMUM QUALIFICATIONS:
Education and Experience: Associate's Degree in Medical Billing or Pharmacy Technician, or at least sixty to sixty-four approved college credits. At least one (1) year of experience as a pharmacy technician or in a similar position.
"Proven experience may be replaced by previously established requirements."
Certifications / Licenses: A valid Pharmacy Technician License and Registration is preferred.
Other: Knowledge of Medical Terminology, CPT, and ICD-10 Codes.
Languages:
Spanish – Basic (comprehensive, writing and verbal)
English – Basic (comprehensive, writing and verbal)
"We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.