Reimbursement Specialist

ADP, Inc.; Town of Florida (NY); On-site; USD 52,000 - 62,000; Full time

Job summary

ADP, Inc. is seeking a Reimbursement Specialist to research and investigate drug or treatment benefit coverage for MD offices. You will handle benefit investigations, update claim details, and communicate results to case management.

The role requires 1–2 years in pharmacy or insurance verification, strong customer service, and HIPAA awareness. A two-year degree or equivalent in healthcare is preferred; you will work closely with the Program Manager and Case Manager.

Qualifications

• Requires 1–2 years in pharmacy or insurance verification.
• Experience in pharmacy benefit investigation and adjudication.
• Associate's degree or equivalent in healthcare preferred; high school diploma required.
• Strong customer service and communication skills.
• HIPAA confidentiality maintained.

Responsibilities

• Handle benefit request investigations via test claim, eBV or phone.
• Contact insurance companies to obtain patient benefits.
• Update claim processing information in the patient record (BIN, PCN, ID, Group).
• Document detailed pharmacy benefit results with appropriate information.
• Identify and escalate priority issues to the Case Manager or Program Manager.
• Follow up on Prior authorization status per business rules.
• Document all call information according to procedures.
• Review referrals for information accuracy and completeness.
• Perform other duties as assigned by the Program Manager or Team Lead.

Skills

Pharmacy knowledge

Insurance verification

Customer service

Data entry

Call center

HIPAA compliance

Education

Associate's degree or equivalent in healthcare

High School Diploma or GED

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Reimbursement Specialist

Position Objective: The Reimbursement Specialist researches and investigates drug or treatment specific coverage and benefits to assist MDOs (medical doctors' offices).

Accountability: The incumbent will report to the Program Manager.

Essential Functions:

• Handles benefit request investigations submitted by MD offices. Investigations to be conducted via test claim, eBV and/ or phone.
• Contacts insurance companies directly to obtain patient's specialty pharmacy and prescription benefits.
• Updates pharmacy claim processing info i.e. BIN, PCN, ID and Group numbers in the patient record.
• Document detailed pharmacy benefit results with the appropriate information regarding patient's pharmacy benefits and network pharmacy details according to the established triage rules and procedures.
• Handling, detecting and fixing errors within the system to ensure proper benefit retrieval.
• Identify and escalation priority issues to the Case Manager or Program Manager.
• Route information and coverage results appropriately to the Case Manager.
• Follow up on Prior authorization status as required based on business rules.
• Document all call information according to standard operating procedures.
• Review referral and case for information accuracy and completeness, including but not limited to, patient demographics, pharmacy card processing information, prescription quantity, dose, directions and diagnosis code.
• Document missing information if any and relay to the Case Manager for HCP or patient outreach as needed.
• Performs other duties as assigned by the Program Manager or the Team Lead.

Knowledge, Skills & Abilities:

Associate's degree or equivalent from a two-year college, technical school or certificate program in pharmacy and/or healthcare, preferred. High School Diploma or GED, required.

1-2 years' experience in pharmacy or insurance verification environment (i.e. hub services, pharmacy, doctor's office, health plan member services, etc.), required.

Experience in pharmacy benefit investigation, retail pharmacy or specialty pharmacy adjudication, required.

Knowledge in call center telephony technology

High level of customer service, interpersonal skills, and highly effective in working objectively with a diverse group of people.

Excellent verbal/written communication skills, self-discipline, and attention to detail.

Proficient in data entry, computer skills, and able to learn the department's software system.

Must be a team player willing to accept organizational and team goals, and function with minimal supervision.

Maintain HIPAA patient confidentiality, as well as discretion regarding proprietary company information.

Adaptable, able to shift gears and focus based on company and team needs.