Eligibility Senior Representative- Accredo- Remote

The Eligibility Senior Representative performs specialized patient access functions requiring an advanced understanding of insurance benefits and internal processes in order to successfully liaise with Payers, Pharma, Physicians and Patients.

This role directly interfaces with external clients and requires a high level of independent judgment and a degree of forward planning and anticipation of needs/issues in order to establish and maintain effective relationships with clients to gain their trust and support.

Relies on experience and knowledge of industry best practices to identify exposures to the company and facilitates leadership's knowledge of pending referrals that may have an adverse impact on company goals and the patient experience.

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, researches & resolves issues impacting revenue optimization.


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


* Contacts benefit providers to gather policy benefits/limitations.


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


* Directly interfaces with external clients.


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


* Provide expert assistance to clients on patient status.


* Liaison for 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 judgement in handling pt or more complex client complaints, escalating as appropriate.


* Completes other projects and additional duties as assigned.

QUALIFICATIONS


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


* 3-5 years of relevant experience.


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


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


* Patient Access knowledge.


* Extensive knowledge of ESI products and services a must.


* Experience training and coaching less experienced staff with patience to explain details and processes repeatedly.


* Excellent communication skills.

Including phone calls, written, and meeting presentation.


* Demonstrated ability to handle challenging customers in a professional manner.
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