Insurance Access Specialist

Role Overview:

This key position directly collaborates with healthcare professionals and insurance providers to gather comprehensive information regarding a patient's insurance coverage for specific pharmaceutical products.

The successful candidate will support healthcare providers in addressing inquiries related to coding and billing, navigating complex reimbursement challenges, and facilitating prior authorizations for an assigned caseload. They will also assist in navigating the appeals process to secure access to medications. The specialist must ensure cases progress through the process as required, adhering to established standards and procedures while providing exceptional service quality.

Main Responsibilities:

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• Conduct thorough investigations into patient benefits by making outbound calls to payers to verify insurance benefit information, navigate complex reimbursement barriers, and seek resources to overcome these barriers">
• Verify patient-specific benefits and document details, including coverage, cost share, and access/provider options">
• Identify any coverage restrictions and provide insights on how to expedite patient access">
• Document and initiate prior authorization processes and claims appeals">
• Report reimbursement trends or delays in coverage to management">
• Act as a liaison for field representatives, healthcare providers, and patients">

Required Skills and Qualifications:

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• Demonstrated expertise in Major Medical & Pharmacy Benefit Coverage">
• 2-3 years of experience in benefit investigation, involving analysis and interpretation of insurance coverage">
• 2-3 years of experience interacting with healthcare providers regarding health insurance plan requirements">
• Exceptional verbal communication skills and grammar">
• Salesforce system experience preferred">

Competencies:

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• Adaptability: Adapts to changes in the work environment, manages competing demands, and is able to deal with frequent change, delays, or unexpected events">
• Attendance/Punctuality: Consistently at work and on time, ensures work responsibilities are covered when absent, and arrives at meetings and appointments on time">
• Customer Service: Manages difficult or emotional customer situations, responds promptly to customer needs, solicits customer feedback to improve service, and responds to requests for service and assistance">
• Ethics: Treats people with respect, keeps commitments, inspires trust in others, works with integrity and ethically, and upholds organizational values">
• Interpersonal Skills: Focuses on solving conflict rather than blaming, maintains confidentiality, listens to others without interrupting, keeps emotions under control, and remains open to others' ideas and tries new things">
• Oral Communication: Speaks clearly and persuasively in positive or negative situations, listens and gets clarification, responds well to questions, demonstrates group presentation skills, and participates in meetings">
• Organizational Support: Follows policies and procedures, completes administrative tasks correctly and on time, supports organization's goals and values, benefits organization through outside activities, supports affirmative action, and respects diversity">
• Professionalism: Approaches others in a tactful manner, reacts well under pressure, treats others with respect and consideration regardless of their status or position, accepts responsibility for own actions, and follows through on commitments">
• Quality: Demonstrates accuracy and thoroughness, looks for ways to improve and promote quality, applies feedback to improve performance, monitors own work to ensure quality, balances team and individual responsibilities, exhibits objectivity and openness to others' views, gives and welcomes feedback, contributes to building a positive team spirit, puts success of the team above own interests, and supports everyone's efforts to succeed">