Insurance Verifier 1

The responsibility of the Verifier I is to work in assigned areas of insurance verification on an efficient level within the team. The Verifier I will have knowledge of verification duties to assist, and effectively communicate with others externally and interdepartmentally on the processing of pharmacy and major medical claims.

Essential Job Functions:

Includes but is not limited to the following. Other duties may be assigned.

• Maintains Axium’s Service Model Expectation specific to assigned lists/queues

• 24-48 hour touch time – (Follow up)
• 4-5 hour touch time – (NEW) o 2 hour touch time – (Axium Cannot Service)
• Metrics: Follow ups 3-4 per hour, NEW 1-2 per hour
• Average of 21-30 referrals touched per day

• Gather appropriate documentation and accurately & efficiently complete Clinical Prior Authorization Questionnaires • Adjudication of primary and secondary insurances for prescription claims

• Check benefits and coverage to ensure appropriate reimbursement

• Create verification note explaining benefits and other necessary information

• Determine if prior authorization of pre-cert is necessary and work accordingly

• Effectively interpret AND resolve PBM rejections.

• Efficiently work different list/queue upon request to support team metric expectations

• Ensure daily re-adjudication of prescription NCPDP claims • Initiate and complete all necessary documentation for “Transitional Fills”

• Input required patient data information into system

• Maintain processing/reject resolution skills specific to live claims (RX and Major Medical) via CPR+ according to applicable insurance and company policy

• Maintains current status specific to applicable and assigned lists/queues

• Prioritization of prescription processing to meet delivery deadlines • Process/reverse online claims as required

• Provide efficient and timely feedback to Sr. team member(s) or Supervisor on any follow up, service or training concerns

• Provide efficient and timely follow up

• Provide interdepartmental support as needed • Renewal of Copay Assistance – PAP cards as needed

• Respond to and resolve difficult verification issues where appropriate

• Support group and management efforts with a positive attitude

• Timely communication of delays to Patient, Sales Team, and/or MDO due to processing issues such as: New Ins/New PA required, Termed Coverage, Manufacturer Transfers, etc.

• Timely communication to the PAP department to inform of patient’s PAPs that are nearing exhaustion, or require additional funds

• Verify insurance for limits and parameters of policy

• Data Entry (Non - Cpht)

• Intermediate understanding of Insurance and Requirements/Restrictions

• Attention to detail • Claim adjudication rejection Interpretation

• Rejection Resolution

• Proper initiation of prior authorization • Proper Follow Up on cases

• Basic math skills

Desired Previous Job Experience

• Must have 6 months to 2 years of verification experience within a specialty pharmaceutical environment

• Be able to secure Prior Authorizations & have comprehensive knowledge of payor types

• Must be able to multitask and work well with others under time constraints

• Must possess excellent verbal & written communication skills

• Must know all aspects of insurances and be willing to learn the managed care environments and TPA

• Must be willing to seek out all possible reimbursement opportunities

• Must be able to multi-task efficiently

• Must be able to work well with other departments

All your information will be kept confidential according to EEO guidelines.