Eligibility Representative

Job Description

The Eligibility Representative delivers straight forward administrative and/or other basic business services in Eligibility.

Implements and maintains eligibility for benefits.

Implements, updates, and maintains automated, direct connect and/or manual eligibility data.

Interacts with internal partners and/or external clients/vendors.

Generates reports to identify and resolve discrepancies.

Identifies process improvement opportunities for own cases.

May negotiate and resolve eligibility with clients.

May provide technical support for the electronic processing of eligibility.

Ensures customer data is installed accurately and timely.

Good knowledge and understanding of Eligibility and business/operating processes and procedures.

Acts as a liaison between both internal and external resources to reduce client abrasion, facilitate the timely processing of referrals and provide accurate status reporting to clients

ESSENTIAL FUNCTIONS


* Facilitates cross-functional resolution of drug coverage issues & proactively address, research & resolves issues impacting revenue optimization.


* Performs medical /pharmacy benefits verification requiring complex decision skills based on payer and process knowledge resulting in onboarding or no starting specialty patients.


* Contacts benefit providers to gather policy benefits/limitations.


* Coordinating and ensuring the services provided will be reimbursable (e.g., deductible amounts, co-payments, effective date, levels of care, authorization, etc.).


* Directly interfaces with external clients.


* Provide expert assistance to clients on patient status.


* Liaison for the company providing referral status reporting.


* May negotiate pricing for non-contracted payers and authorize patient services and ensure proper pricing is indicated in RxHome.


* Handle Escalations.


* Use discretion & independent judgment in handling pt or more complex client complaints, escalating as appropriate.


* Completes other projects and additional duties as assigned.

QUALIFICATIONS


* Must have APC clearance experience, APC phone queue experience or APC copay experience.


* High school diploma or GED required bachelor's degree preferred.


* Must have a minimum of 3 years of relevant working experience.


* Must have Health care experience with medical insurance knowledge and terminology and experience in patient access.


* Intermediate data entry skills and working knowledge of Microsoft Office.


* Excellent phone presentation and communication skills.


* Demonstrated ability to handle professionally challenging customers.


* Ability to adapt in a dynamic work environment and make decisions with minimal supervision.


* Advanced problem-solving skills and the ability to work collaboratively with other departments to resolve issues with innovative solutions.

ABOUT THE DEPARTMENT
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