Reimbursement Counselor Resume Samples

Description :

1. Responsible for undertaking the management of specific projects or cases assigned with regards to reimbursement, within the Specialty Services department.
2. Coordinated and managed all aspects required in order to obtain prescription drug coverage for patients.
3. Coordinated cases with insurance companies, physician' offices and health care professionals in order to maximize reimbursement solutions.
4. Worked interactively with patients and their healthcare providers to complete enrollment activities, coordinate distribution of educational materials, and program inquiries.
5. Answered basic clinical and program inquiries.
6. Coordinated access to therapies, schedules and conducts appropriate follow-up, and facilitates access to appropriate support services.
7. Facilitated access to appropriate support services, including reimbursement counseling, nursing hotline, and support.
8. Processed incoming enrollment forms for program.
9. Supported payer research, health care policy library, and state management.

Experience

2-5 Years

Level

Junior

Education

MHA

Description :

1. Authorized drug refills and provided detailed prescription information to pharmacies to ensure patients receive access to therapy.
2. Worked interactively with multiple sclerosis patients and their healthcare providers to complete enrollment activities.
3. Coordinate distribution of educational materials answered clinical and program inquiries, and help coordinate access to therapies through the patient's healthcare insurance.
4. Reviewed and processed financial assistance applications for high dollar multiple sclerosis medications through analysis of tax documentation and or soft credit reports.
5. Ensured income verification was within financial parameters set by the client.
6. Provided quality assurance on Risk Evaluation Mitigation Strategy (REMS) documents required by the FDA for various parties.
7. Helped maintain multiple sclerosis recall program, ensuring the accuracy of daily data entry and tracking 275+ MS patients and their follow-up schedules.
8. Assisted in Master Patient Index (MPI) data-cleanup project, purging duplicate records and merging relevant data from other sources.

Experience

5-7 Years

Level

Executive

Education

BA

Description :

1. Verification of drug card and/or major medical benefits; Performance of on-line claim tests and resolution of on-line insurance rejections.
2. Determination of potential coverage components of insurance plans is appropriate provisions to cover the therapy as well as differentiate coverage by the site of service.
3. Identification of pricing/reimbursement for patients and/or health care providers.
4. Research of payers to identify existing contracts, determining if specialty drugs are covered by a contract or coverage policy.
5. Classification of which specialty pharmacy provider should dispense on particular cases taking into consideration contractual and other defined operational rules.
6. Determines when it is appropriate to aggressively pursue Assignment of Benefits (AOB) as requested by the treating physician.
7. Obtains authorizations for the full scope of billable therapy (drug/supplies/training/etc.) based on the specific clinical use for that patient; confirming authorizations in writing.

Experience

0-2 Years

Level

Entry Level

Education

PH.D

Description :

1. Thorough knowledge and understanding of medical insurance and how to obtain information from insurance companies.
2. Verify private, government & third party insurance information, including eligibility, out-of-pocket costs, in and out-of-network medical benefits.
3. Obtain verbal and written authorization for planned medical treatment of patients from appropriate sources.
4. Knowledge of HMO, PPO, POS, IND and EPO insurance, meet Minimum verification quota set by billing company per day and entering data in an accurate manner.
5. Maintain confidentiality of company, client and patient information Develop or assess materials that will help employees understand the subjects being taught.
6. and understand the needs of the employees and judge what will work.
7. Decide the best programs to train their employees and meet the needs of the organization.
8. Present to groups of employees, speak interpersonally with individuals, report to management and meet with vendors.
9. Heavy data entry into the billing system and thorough knowledge of the company's database.

Experience

2-5 Years

Level

Junior

Education

HS

Description :

1. Provide comprehensive case management and reimbursement services in order to facilitate patient access to various drug and treatment therapy for multiple disease states.
2. Assist with several patient assistance and reimbursement support programs to assist patients and providers in obtaining access to the medications of numerous drug manufactures.
3. Provide ongoing case management and assistance to patients with problems or questions concerning their insurance coverage.
4. Answer questions on payer policies related to these products' coverage and reimbursement.
5. Assist patients with verification and coordination of insurance benefits.
6. Coordinate prior authorization and proof of medical necessity requirements with the patient, physician, and insurer in order to obtain medication coverage.
7. Alternate Coverage Research is conducted on all patient and providers when requested regardless of the eligibility determination.
8. Provide alternate sources of assistance in denied cases and additional sources of assistance in approved cases.

Experience

2-5 Years

Level

Junior

Education

Diploma

Description :

1. Assisted with the successful completion of an Annual reimbursement re-verification project for major medical and prescription benefits.
   
2. Processes all reimbursements in accordance with the three day established guidelines and department policy.
3. Conducted benefit investigation to insurance patient's prescription would cover specialty drug prescribed by a health care professional.
4. Worked with management and team members to ensure effective and efficient processing of accounts.
5. Communicates with patients, payers, team, and management in a clear honest, tactful and respectful manner.
6. Accurately and appropriately document all communication, reimbursement arrangements and follow up actions on the patient's account.
7. Ensures compliance with coding requirements including HCPCS, CPT ICD-9, NDC, diagnosis codes as well as Federal, State, and/or Managed Care requirements.

Experience

0-2 Years

Level

Entry Level

Education

Diploma

Description :

1. Collects and reviews all patient insurance benefit information, to the degree authorized by the SOP of the program.
2. Provides assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications.
3. Completes and submits all necessary insurance forms and electronic claims to process the claims in a timely manner as required by all third party payors.
4. Researches and resolves any electronic claim denials.
5. Researches and resolves any claim denials or underpayment of claims.
6. Investigates /brings resolution to on-line insurance rejections.
7. Obtains authorizations for the full scope of billable therapy based on the specific clinical use for that patient, confirm authorizations in writing.
8. Define the scope of authorization (medical necessity/specific dosing/pricing).
9. Maintains frequent phone contact with provider representatives, third party customer service representatives, pharmacy staff, and case managers.

Experience

5-7 Years

Level

Executive

Education

BA

Description :

1. Administered various health benefit programs, such as group insurance, life, medical and dental, accident and disability, insurance, pensions, investments, and savings and health maintenance organizations.
2. Managed data on benefit enrollments, claims processing and self-billings of insurance for the COBRA program.
3. Processed and maintained all status reports and pay changes, both on computer and paper system.
4. Prepared and maintained patient's files, assuring accuracy, compliance and confidentiality; processed unemployment claims, verifications, I9 status, and State regulations.
5. Researched payers to identify existing contracts and policy coverage of specialty products.
6. Determined potential coverage components of insurance plans for therapy coverage, and differentiated coverage by the site of service.
7. Identified and confirmed pricing and reimbursement for patients and health care providers.
8. Provided support services to drug manufacturers and biotechnology companies on the use and dispensation of their products.

Experience

2-5 Years

Level

Junior

Education

BS

Description :

1. Provides assistance to physician office staff and patients too complete and submit all necessary insurance forms and program applications.
2. Completes and submits all necessary insurance forms and electronic claims to process the claims in a timely manner as required by all third party payors.
3. Researches and resolves any electronic claim denials.
4. Provides exceptional customer service to internal and external customers, resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
5. Maintains frequent phone contact with provider representatives, third party customer service representatives, pharmacy staff, and case managers.
6. Provides all necessary documentation required to expedite payments.
7. Including demographic, authorization/referrals, National Provider Identification (NPI) number, and referring physicians.

Experience

7-10 Years

Level

Management

Education

Associate

Description :

1. Provide day-to-day mentoring to 65 team members on performance metrics, program processes ensuring team members are performing in-line with program standards.
2. Provided input on the individual, as well as, group training needs.
3. Train new and current team members on program standard operating procedures provided routine updates and addressed team member questions.
4. Conduct quality review assessments on Patient Accounts and assisted with implementing new approaches to improve, streamline and sustain desired customer service levels.
5. Interface and engaged with associates at least 50% of the time to assist with answering questions and provide mentoring.
6. Identify new approaches to enhance current service.
7. Identify problems, investigates, recommends, and implements solutions.
8. Responsible for clarifying and documenting business requirements and providing consultative support to business partners on the appropriate use of data.

Experience

2-5 Years

Level

Junior

Education

MHA

Description :

1. Collects and reviews all patient insurance benefit information, to the degree authorized by the SOP of the program.
2. Provides assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications.
3. Completes and submits all necessary insurance forms and electronic claims to process the claims in a timely manner as required by all third party payers.
4. Researches and resolves any electronic claim denials.
5. Researches and resolves any claim denials or underpayment of claims.
6. Effectively utilizes various means for collections, including but not limited to phone, fax, mail, and online methods.
7. Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
8. Maintains frequent phone contact with provider representatives, third party customer service representatives, pharmacy staff, and case managers.

Experience

0-2 Years

Level

Entry Level

Education

HA

Description :

1. Collects and reviews all patient insurance benefit information, to the degree authorized by the SOP of the program.
2. Provides assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications.
3. Completes and submits all necessary insurance forms and electronic claims to process the claims in a timely manner as required by all third party payer.
4. Researches and resolves any electronic claim denials.
5. Researches and resolves any claim denials or underpayment of claims.
6. Effectively utilizes various means for collections, including but not limited to phone, fax, mail, and online methods.
7. Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
8. Maintains frequent phone contact with provider representatives, third party customer service representatives, pharmacy staff, and case managers.

Experience

7-10 Years

Level

Management

Education

HS

Description :

1. Organize and prioritize caseload daily to maximum production and remain in compliance while maintaining quality customer service.
2. A thorough understanding of health benefit structures and the ability to identify and correct inaccurate information.
3. Identifying and correcting mistakes in data entry and completed narratives that prevent a delay in patient starting or continuing therapy.
4. Obtain the process for completing prior authorizations and appeals for medications for all patients starting and remaining on therapy.
5. Ensure all pharmacy orders for PAP and replacement medications are complete, accurate, and forwarded to the pharmacy before the daily cut-off time.
6. Assist in one-on-one and group training with new associates which includes monitoring phone calls with a health insurance representative and completing quality assurance on data entry and accuracy of benefits.
7. Adherence to the program's SOPs and all policy changes as they arise.

Experience

7-10 Years

Level

Management

Education

BA

Description :

1. Collects and reviews all patient insurance benefit information while following organizational guidelines.
2. Provides assistance to physician office, staff and patients to complete and submit all necessary insurance forms and program applications.
3. Maintains frequent phone contact with provider representatives, third party customer service representatives, pharmacy staff, and case managers.
4. Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
5. Reports any reimbursement trends/delays to supervisor.
6. Works on problems of moderate scope where analysis of data requires a review of a variety of factors.
7. Exercises judgment within defined standard operating procedures to determine appropriate action.
8. Maintains confidentiality in regards to patient account status and the financial affairs of clinic/corporation.

Experience

10+ Years

Level

Senior

Education

MBA

Description :

1. Evaluating and processing enrollment applications in accordance with program eligibility criteria.
2. Completing detailed insurance benefit verifications through commercial and government payers.
3. Facilitating access to appropriate support services, including Reimbursement counseling and nursing hotline support.
4. Resolving patient and providers request in a timely and accurate manner. 
5. Conducting follow-ups via phone, mail, and fax regarding all missing enrollment information for processing.
6. Maintaining frequent phone contact and professional interaction with patients and providers.
7. Scheduling and coordinating shipments to Patients home through a specialty pharmacy and to the provider office through the program client.

Experience

10+ Years

Level

Senior

Education

HS