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QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/ or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

Educational/Work Experience

• Associate degree in health related field or 2-5 years direct work experience in health related field
• Understanding of Medicare/Medicaid/Insurance Pay types, medical terminology, and brand/generic medications required
• Intermediate knowledge of Microsoft Word and Excel, or like applications

Other Qualifications

• Ability to exhibit strong oral and written customer service skills
• Ability to effectively interact with all levels of department representatives both internally and externally
• Ability to interpret and understand prescription directions
• Ability to multitask and adhere to timelines

 

Essential Duties and Responsibilities include the following.  Other duties may be assigned.

 

1. Prescription processing                                                                                            (55%)
   • Data Entry of new and refill orders which includes:
     1. Interprets prescription directions and communicates clarification to the facility as needed.
     2. Identifies orders that can not be processed due to coverage issues, missing information, or inability to read/understand
     3. Inputs medication orders with correct medication and frequency.
     4. Ensures formulary substitutions are made appropriately based on facility contracts
     5. Completes appropriate paperwork/forms, as well as communicates order exceptions and any other discrepancies to facilities and team leaders
     6. Transmits all third party and Medicaid online claims at time of order entry to ensure payment.
     7. Maintains an understanding of the special requirements for each payer including Medicare/Managed Care/Medicaid Formulary and Non-Formulary/Third Party Insurance as well as communicates discrepancies to facilities regarding:
        • Formularies
        • Rejections
        • Contract requirements
        • Exclusions and Non-covered medications
     8. Adheres to special Facility processing requirements (i.e. House Stock, Non-covered Medication Policies)
     9. Updates patient room number if received on a telephone order
     10. Changes profile doctor when notified on a telephone order

 

1. Admissions                                                                                                                   (15%)
   • Process new/ readmission information for residents:

1. Obtains complete resident face sheet from facility and enters all data.
   1. Prevents duplication of account by conducting Universal Search   for patient in Pharmacy System
2. Enter per diem date if required.
3. Obtains and inputs correct admissions history and appropriate transfers/ discharges information
4. Shared responsibility with the billing department in resolving Mason returned mail
5. Researches and responds to email tree on any problem admissions
6. Checks under “payment plans” (Frameworks “E1”) to see if patient has Part D insurance
7. Obtains, verifies and enters appropriate pay source information by next business day
8. Enters Hospice formulary, if provided upon admission, as well as listing diagnosis
9. Adds physicians to Pharmacy Information System
10. Responsible for adding patient face sheet information for a facility start-up
11. Responsible for placing expired patients on “bed hold” when notified by facility on telephone order

 

1. Third Party Submission/Rejections                                                      (15%)
   • Process all insurance claims at time of order entry
     1. Processes all Mason online billing rejections daily; resolves all rejections within 48 hours.
     2. When applicable, completes and distributes prior authorizations according to facility contract
     3. Acquires and maintains appropriate logs of prior authorizations for follow up
     4.  Investigates and resolves insurance inquires
     5. Communicates to pharmacists any suggested covered alternative recommended by 3^rd party payor.
     6. Resolves cycle fill rejections

 

1. Customer Relations                                                                                                   (10%)

• Acknowledges and responds to all daily emails and phone calls received prior to one hour of the end of employee’s shift on same business day.

 

1. Other Duties                                                                                                                (5%)

• Acts as back up for Triage Department as needed
• Attends training as provided for self-improvement and quality of work
• Accepts other duties as assigned