- Verify pharmacy benefits including coverage, eligibility, copay, coinsurance, deductibles, and network status.
- Determine patient eligibility for admission based on benefit verification results.
- Triage prescriptions for patients who cannot be admitted, ensuring appropriate follow-up or redirection.
- Identify payer requirements such as prior authorizations, step therapy, and specialty drug restrictions.
- Determine whether prior authorization reviews are handled by the payer directly or by a third-party vendor.
- Identify payers based on Rx BINs, Rx PCNs, and Rx Group numbers.
- Use payer portals, phone, fax, and internal systems to obtain benefit information.
- Collect and submit documentation from prescribers to meet payer requirements.
- Accurately document benefit verification results in pharmacy systems.
- Troubleshoot rejected claims and perform necessary claim adjustments.
- Assist in obtaining overrides from payers, including quantity limits, refill-too-soon, and vacation overrides.
- Maintain awareness of payer-preferred specialty pharmacies and ensure prescriptions are routed accordingly.
- Stay current on payer policies and communicate updates to the team.
- Maintain compliance with HIPAA and other regulatory standards.
- High school diploma or GED required
- 1-3 years of experience in benefit verification, medical billing, health insurance, or specialty pharmacy.
- Familiarity with commercial insurance, Medicare, Medicaid, and specialty drug coverage.
- Knowledge of Rx BINs, PCNs, Group numbers, and payer identification.
- Understanding of prior authorization routing and third-party review processes.
- Experience with claim troubleshooting and payer override procedures.
- Strong verbal and written communication skills.
- Detail-oriented with excellent organizational and multitasking abilities.
- Proficient in Microsoft Office and pharmacy/benefit verification systems.
- Ability to meet productivity and accuracy targets in a fast-paced environment.
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Benefits Verification Specialist - Covina - LTC PHARMA HLDG LLC
Description
JOB SUMMARY:
Polaris Specialty Pharmacy is seeking a Benefits Verification specialist to support patient access to specialty medications. This role is essential in verifying insurance coverage, identifying payer requirements, and facilitating prior authorizations.
The associate will also assess patient eligibility for admission based on benefit verification results and triage prescriptions for patients who cannot be admitted.
This position requires familiarity with payer-preferred specialty pharmacies and coordination across multiple stakeholders to ensure timely and accurate therapy initiation.
DUTIES/RESPONSIBILITIES:
QUALIFICATIONS/COMPENTECIES:
PHYSICAL DEMANDS
The physical demands described here are representative of those that should be met by an employee to successfully perform the essential functions of this job:
§ May sit or stand seven (7) to ten (10) hours per day
§ The employee is occasionally required to sit; climb or balance; and stoop, kneel, bend, walk
§ May be necessary to work extended hours as needed
§ May lift and/or move up to 30 pounds
§ The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this role
HOLIDAY & PTO POLICY
§ Paid holidays are provided annually, with 6 days offered each year, along with 5 sick days.
§ Employees earn up to 10 PTO days each year, with rollover options and milestone bonuses.
§ Employees have the option to cash out up to 10 PTO hours each quarter for added financial flexibility.
Please note, because we are a pharmacy most of our locations are open 24-hours a day, 7 days a week and therefore schedules may change as determined by the needs of the business.
BENEFITS for full time Employees§ Medical, Dental, and Vision insurance
§ 401 (k) (available for Part Time & Full Time EEs)
§ Company Paid Life insurance
§ Short-term and Long-term disability insurance
§ Tuition reimbursement
§ Personal Time Off (PTO)
§ Competitive pay with annual performance reviews and merit-based raises
§ Career growth potential
§ Annual on-site voluntary Flu Vaccines
§ Employee referral bonus program
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