Authorization Specialist - Buy and Bill Pharmacy - Medical Billing
On-siteGreenville, South Carolina, United States
Job Summary
Resolve new and aged accounts receivable by processing professional, governmental, and non-governmental claims, including denials, credits, and high-priority accounts. Verify patient benefits and eligibility for buy and bill drugs, then obtain required authorizations and submit claims to insurance companies. Track claim status, interpret scrubber edits, and prepare appeal letters for technical denials by submitting medical documentation. Communicate with payer resources via portals, email, and telephone to resolve payment discrepancies and seek resolution for problematic accounts. Maintain quality and productivity results meeting departmental standards. Apply for co-pay assistance programs as applicable and interpret payer clinical guidelines to identify contract variances affecting reimbursement.
Required Qualifications
- Must have had at least 2-3 years accounts receivable experience in a physician office setting
- Must have a High School Diploma/GED
- Must have the ability to interpret payer clinical guidelines and identify contract variances affecting reimbursement
- Must demonstrate clear proficiency in third-party billing requirements to include federal, state, and commercial/managed care payers
- Must be able to verify patient benefits and eligibility for buy and bill drugs
- Must be able to obtain authorization for buy and bill drugs as required by the various payors
- Must be able to submit claims to insurance companies for buy and bill drug administration and related services
- Must be able to track claim status and follow up on denials or incomplete/pending claims
- Must be able to prepare appeal letters for technical denials by accessing specific payer appeal forms, submitting appropriate medical documentation and tracking appeal resolution
- Must be able to interpret claim scrubber edits/rejections and take appropriate action necessary to resolve issues
- Must be able to seek resolution to problematic accounts and payment discrepancies
Desired Qualifications
- Has previous Buy and Bill experience preferred
- General Knowledge of HCPCS, CPT-4 and ICD-10 coding and/or medical terminology
- Familiar with multiple payer requirements and regulations for claims processing
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