Insurance Verifier 1

Axium Healthcare Pharmacy, Inc.; Irvine (CA); On-site; USD 52,000 - 72,000; Full time

Job summary

Axium Healthcare Pharmacy, Inc. is seeking a Verifier I to join our team and handle insurance verification across RX and major medical claims. You will gather and review documentation, communicate with departments, and ensure accurate reimbursement through effective prior authorizations and re-checks.

Responsibilities include processing verifications, completing PA questionnaires, and resolving PBM rejections while maintaining timely updates and cooperation with the patient care team.

Qualifications

• Must have intermediate understanding of Insurance and Requirements/Restrictions.
• Attention to detail is essential for accurate verifications and documentation.
• Ability to interpret claim adjudication rejections and respond appropriately.
• Ability to initiate prior authorizations properly and track progress.
• Effective follow-up on cases to ensure timely processing.
• Basic math skills for calculations and reconciling patient data.

Responsibilities

• Verifies insurance for RX and major medical claims in assigned areas.
• Completes Clinical Prior Authorization questionnaires accurately.
• Adjudicates primary and secondary insurances for prescription claims.
• Checks benefits and coverage to ensure appropriate reimbursement.
• Creates verification notes with benefits information for teams.
• Interprets and resolves PBM rejections efficiently.
• Maintains queues and supports team metrics with timely updates.
• Supports PAP and renewal processes as needed.
• Communicates delays and issues to patients, sales, and management.

Skills

Attention to detail

Insurance requirements

Claim adjudication

Prior authorization initiation

Follow-up skills

Numerical/mathematical skills

Job description

At Axium Healthcare Pharmacy, Inc., we believe in a better quality of life for patients and their healthcare partners when treating and managing the most complex conditions. We believe in relationships that make life easier, and where a helping hand and better clinical, economical, and overall health outcomes are always within reach, 24 x 7 x 365. Our mission is simple. We aim to partner with and guide our patients to their best possible outcomes. Our longstanding vision is to help our patients and healthcare providers reach and create a better path to treating and managing complex conditions, making their lives easier and giving them hope for a healthier future. Specialty pharmacy is not a new concept. In fact, Axium did not invent specialty pharmacy. But, we did invent a better way to do it. We do it through a combination of clinical expertise, nationwide reach and the delivery of committed, caring, unmatched service and support for everyone, every time with no excuses. And, we’ve been doing it for years. We invite you to ask us what we can do for you. Our answer to you will almost always be: “Yes, we do.” Established in 2000 and based in Lake Mary, Florida, Axium is a nationwide clinical specialty pharmacy that makes life easier for those managing chronic disease and complex therapies by offering a helping hand and a better path to therapy management. We are licensed and permitted to operate in all 50 states and Puerto Rico, and specialize in providing patients, physicians, nurses, health plans, and other health care providers and partners with injectable and oral brand-name products. Our focus is to “Improve outcomes one relationship at a time,” and we achieve this through an experienced patient care team of doctors of pharmacy, registered nurses, reimbursement specialists, and dedicated patient care coordinators; all of whom deliver the highest level of comprehensive care and clinical support with every prescription.

Job Description

The responsibility of the Verifier I is to work in assigned areas of insurance verification on an efficient level within the team. The Verifier I will have knowledge of verification duties to assist, and effectively communicate with others externally and interdepartmentally on the processing of pharmacy and major medical claims.

Essential Job Functions:

Includes but is not limited to the following. Other duties may be assigned.

• Maintains Axium’s Service Model Expectation specific to assigned lists/queues
  • 24-48 hour touch time – (Follow up)
  • 4-5 hour touch time – (NEW)o 2 hour touch time – (Axium Cannot Service)
  • Metrics: Follow ups 3-4 per hour, NEW 1-2 per hour
  • Average of 21-30 referrals touched per day
• Gather appropriate documentation and accurately & efficiently complete Clinical Prior Authorization Questionnaires
• Adjudication of primary and secondary insurances for prescription claims
• Check benefits and coverage to ensure appropriate reimbursement
• Create verification note explaining benefits and other necessary information
• Determine if prior authorization of pre-cert is necessary and work accordingly
• Effectively interpret AND resolve PBM rejections.
• Efficiently work different list/queue upon request to support team metric expectations
• Ensure daily re-adjudication of prescription NCPDP claims
• Initiate and complete all necessary documentation for “Transitional Fills”
• Input required patient data information into system
• Maintain processing/reject resolution skills specific to live claims (RX and Major Medical) via CPR+ according to applicable insurance and company policy
• Maintains current status specific to applicable and assigned lists/queues
• Prioritization of prescription processing to meet delivery deadlines
• Process/reverse online claims as required
• Provide efficient and timely feedback to Sr. team member(s) or Supervisor on any follow up, service or training concerns
• Provide efficient and timely follow up
• Provide interdepartmental support as needed
• Renewal of Copay Assistance – PAP cards as needed
• Respond to and resolve difficult verification issues where appropriate
• Support group and management efforts with a positive attitude
• Timely communication of delays to Patient, Sales Team, and/or MDO due to processing issues such as: New Ins/New PA required, Termed Coverage, Manufacturer Transfers, etc.
• Timely communication to the PAP department to inform of patient’s PAPs that are nearing exhaustion, or require additional funds
• Verify insurance for limits and parameters of policy

Qualifications

• Intermediate understanding of Insurance and Requirements/Restrictions
• Attention to detail
• Claim adjudication rejection Interpretation
• Proper initiation of prior authorization
• Proper Follow Up on cases
• Basic math skills

Desired Previous Job Experience

• Must have 6 months to 2 years of verification experience within a specialty pharmaceutical environment
• Be able to secure Prior Authorizations & have comprehensive knowledge of payor types
• Must be able to multitask and work well with others under time constraints
• Must possess excellent verbal & written communication skills
• Must know all aspects of insurances and be willing to learn the managed care environments and TPA
• Must be willing to seek out all possible reimbursement opportunities
• Must be able to multi-task efficiently
• Must be able to work well with other departments

Additional Information

All your information will be kept confidential according to EEO guidelines.