Express Scripts Sr. Prior Authorization Representative - Accredo in Warrendale, Pennsylvania

POSITION SUMMARY

Obtains required documentation, verifies insurance benefits, completes shipments, and may complete quality assurance audits as needed. Processed invoices in preparation for billing and transfer payor information regarding billing and reimbursement criteria. Negotiates pricing as necessary and authorizes patient service. Ensures data accuracy in Rx Home including payer pricing. May conduct invoice editing and revenue reconciliation for booking inventory.

ESSENTIAL FUNCTIONS

  • Contact benefit providers and/or payers to gather policy benefit limitations and ensure services provided are reimbursable; deductable amounts, co-payments, effective date, levels of care, authorization, visit limitations, documentation required to process claims).
  • Documents all communication.
  • Facilitate communication for acceptance or denial of new patient referral/change in therapy.
  • Provide updates to physician and sales on the status of pending referrals.
  • Provide billing and reimbursement requirements.
  • Assist with billing, payer, and patient issues.
  • Submit required documentation.
  • Notify patient or responsible party of possible financial responsibility before start of service if business rules require.
  • Negotiate pricing based on pricing grids for non-contracted payers.
  • Authorize patient services and ensure proper payer pricing is indicated in Rx Home.
  • Contact/inform branch staff if no payer source is available.
  • Ensure accounts requiring authorizations and re-authorizations are identified, secured, and updated in Rx Home prior to each shipment.
  • Notify service delivery staff if authorization cannot be obtained.
  • Update patient information with address/benefit changes per payer request and make correction to ensure payment.
  • Conduct financial quality assurance reviews (DVR, shipment QA, insurance and authorization screens, etc.) of patient and payer related data post start of care and shipment to validate and ensure services provided will be reimbursed.
  • May conduct invoice editing and daily revenue accuracy reconciliation as required for the SDU in accordance with the Invoice Editing processes and essential duties.
  • Special projects as assigned.

QUALIFICATIONS

  • High School Diploma or GED required, bachelor’s degree preferred.
  • 3 – 5 years relevant experience.
  • Working knowledge of Microsoft Office.
  • Excellent Customer Service Skills - patience to explain details and processes repeatedly, excellent phone presentation and communication skills.
  • Demonstrated ability to handle challenging customers in a professional manner.
  • Ability to adapt in a dynamic work environment and make decisions with minimal supervision.
  • Advance problem solving skills and the ability to work collaboratively with other departments to resolve complex issues with innovative solutions.
  • Ability to work a flexible schedule.

ABOUT THE DEPARTMENT

Through the range of healthcare products and services Accredo offers, team members provide in-depth care for patients with chronic health conditions like hemophilia, oncology, rheumatoid arthritis and growth hormone deficiencies. In addition to the wide range of healthcare products offered to these patients, we provide comprehensive management services, including outcomes measurement, counseling, clinical care management programs, social services and reimbursement services. In these very high-touch roles, employees leave every day knowing they made a positive impact on patient lives.

ABOUT EXPRESS SCRIPTS

Advance your career with the company that makes it easier for people to choose better health.

Express Scripts is a leading healthcare company serving tens of millions of consumers. We are looking for individuals who are passionate, creative and committed to creating systems and service solutions that promote better health outcomes. Join the company that Fortune magazine ranked as one of the "Most Admired Companies" in the pharmacy category. Then, use your intelligence, creativity, integrity and hard work to help us enhance our products and services. We offer a highly competitive base salary and a comprehensive benefits program, including medical, prescription drug, dental, vision, 401(k) with company match, life insurance, paid time off, tuition assistance and an employee stock purchase plan.

Express Scripts is an equal opportunity employer/disability/veteran