The Copay Support/Claims Processing Specialist is a critical role within the organization and is responsible for servicing inbound calls, EOB faxes, and mail (emails, USMail) from pharmacies, patients, Sites of Care, Health Care Providers, copay vendors (PDMI, FHA and Merchant Card processors) and other sources. Required engagement is with pharmacy claim adjudicators, third party medical claim administrators, merchant vendors, finance for manual claim reimbursement, Sites of Care and Health Care Providers.
The Copay Support/Claims Processing Specialist will adjudication, troubleshoot claim rejections, claim reversals, allocation deficiencies, identifying group accumulator and maximizers, provide alternate payment processing method, handle paperwork related to medical procedures, treatments and services submitted by the site of care or health care providers that meet the program business rules for determination of approval, denial, or pending for submission of required information for final determination as well as claim appeal handling.
- Quality control of commercial copay programs
- Collaborate with internal HUB teams on enrollment discrepancies (missing info and duplicates)
- Partners with claim adjudication vendors ensure proper claims processing and data integrity
- Monitor and remediate medical and pharmacy manual data entry errors
- Serve as Subject Matter Expert for internal and external stakeholders on medical and pharmacy Copay claim adjudication issues and platform logic variations
- Provide ongoing insights on specific program trends and system/process opportunities
Patient and Prescriber Support:
- Act as the primary point of contact for handling inquiries from prescribers, patients, external clients, and internal program team members
- Subject Matter Expert on reviewing and processing of medical claims submitted for copay programs where the therapy is primarily processed through a medical benefit
- Thorough understanding of copay program design and elements eligible for payment processing
- Ensure proper CMS form and EOB is provided for each eligible item
- Validate required elements for payment approval are present
- If not partner with HUB to secure missing information
- Create manual medical reimbursement record for submission to finance
- Review Directive Analytics against Net-Suite and make necessary corrections
- Identify applicable programs and guide stakeholders through next steps for patient support
- Accept inbound calls, team chats, and emails. Ensure one-call resolution for patients and providers
- Communicate status updates across all patient support activities in a holistic, clear, and professional manner
- Liaise with program-specific AssistRx resources to secure outcomes and resolve escalations
- Maintain accurate documentation and ensure protection of patient and prescriber information
Requirements
- High school diploma or general education degree (GED), or one to three months related experience and/or training, or equivalent combination of education and experience
- Associate's Degree (AA) or equivalent from a two-year college or technical school, or six months to one year related experience and/or training, or equivalent combination of education and experience
- Computer skills required: Contract Management Systems; Microsoft Office
- Other skills required: Pharmacy Data Management (PDMI), PNC Card Platform
COMPETENCIES:
- Diversity - Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; Educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce
- Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values
- Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information
- Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments
- Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals; Completes tasks on time or notifies appropriate person with an alternate plan
- Initiative - Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Takes independent actions and calculated risks; Looks for and takes advantage of opportunities; Asks for and offers help when needed
- Innovation - Displays original thinking and creativity; Meets challenges with resourcefulness; Generates suggestions for improving work; Develops innovative approaches and ideas; Presents ideas and information in a manner that gets others' attention
- Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; 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; Participates in meetings
- 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; Follows through on commitments
- Project Management - Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages project team activities
- Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness
- Teamwork - 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 team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed
Benefits
- Supportive, progressive, fast-paced environment
- Competitive pay structure
- Matching 401(k) with immediate vesting
- Medical, dental, vision, life, & short-term disability insurance
Why Choose AssistRx:
- Preloaded PTO: 100 hours (12.5 days) PTO upon employment, increasing to 140 hours (17.5 days) upon anniversary
- Tenure vacation bonus: $1,000 upon 3-year anniversary and $2,500 upon 5-year anniversary
- Impactful Work: Join a team that is at the forefront of revolutionizing healthcare by improving patient access to essential medications
- Flexible Culture: Many associates earn the opportunity to work from home after 120 days. Enjoy a flexible and inclusive work culture that values work-life balance and diverse perspectives
- Career Growth: We prioritize a "promote from within mentality". We invest in our employees' growth and development via our Advance Gold program, offering opportunities to expand skill sets and advance within the organization
- Innovation: Contribute to the development of groundbreaking solutions that address complex challenges in the healthcare industry
- Collaborative Environment: Work alongside talented professionals who are dedicated to collaboration, learning, and pushing the boundaries of what's possible. Tell your friends about us! If hired, receive a $750 referral bonus!
Wondering how we recognize our employees for delivering best in class results? Here are some of the awards that our employees receive throughout the year!
- #TransformingLives Honor: This quarterly award program is a peer to peer honor that recognizes and highlights some of the amazing ways that our team members are transforming lives for patients on a daily basis
- Values Award: This quarterly award program recognizes individuals who exhibit one, or many, of our core company values; Excellence, Winning, Respect, Inspiration, and Teamwork
- Vision Award: This annual award program recognizes an individual who has gone above and beyond to support the AssistRx vision to transform lives through access to therapy
AssistRx, Inc. is proud to be an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, religion, color, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, family medical history or genetic information, political affiliation, military service, or other non-merit based factors, or any other protected categories protected by federal, state, or local laws.
All offers of employment with AssistRx are conditional based on the successful completion of a pre-employment background check.
In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. Sponsorship and/or work authorization is not available for this position.
AssistRx does not accept unsolicited resumes from search firms or any other vendor services. Any unsolicited resumes will be considered property of AssistRx and no fee will be paid in the event of a hire.
