Specialty Pharmacy Representative

Jefferson Health; King of Prussia (Montgomery County); On-site; USD 45,000 - 60,000; Full time

Job summary

A leading healthcare provider in King of Prussia seeks a Specialty Pharmacy Representative to assist patients with medication management, claims adjudication, and financial assistance applications. This role involves direct interaction with patients and healthcare providers, ensuring optimal outcomes and adherence to therapy. Ideal candidates will demonstrate strong communication skills and a thorough understanding of insurance processes.

Qualifications

• Knowledge of insurance processes, HIPAA, and patient rights.
• Experience in patient care and pharmacy operations.

Responsibilities

• Adjudicate and review claims responses for reimbursement.
• Schedule delivery of specialty medications to ensure patient adherence.
• Act as liaison between patients and insurance companies.

Skills

Active Listening

Relationship-Building

Customer Conflict Resolution

Knowledge of Medical Terminology

Job description

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Primary Responsibilities

The Specialty Pharmacy Representative I drives our refill queues and assists patients, physicians, and pharmacists in claim adjudication/review, benefit investigations, financial assistance applications, refill/adherence activities, and other programs that optimize outcomes for Jefferson Specialty Pharmacy patients. Responsibilities include entering patient information such as name, date of birth, insurance details, allergies, and medication history into our therapy-specific assessment software. Assist with filling and distributing prescriptions under the supervision of a patient care pharmacist, in accordance with legal requirements.

Essential Functions

• Adjudicate and review claims responses for reimbursement and profitability.
• Analyze claims messages to determine next steps: Prior Authorization, Benefits Investigation, Step Therapy, Non-Formulary, Financial Assistance, etc.
• Schedule delivery of high-dollar/specialty and maintenance medications to ensure patient adherence and compliance.
• Assess patient needs for clinical intervention based on refill responses and other provided information.
• Identify barriers to care, non-compliance, or therapy changes and escalate as appropriate.
• Review and update patient charts for accuracy.
• Explain insurance coverage and copay responsibilities to patients.
• Screen and apply for financial assistance on behalf of patients.
• Print paperwork and fill prescriptions under pharmacist supervision.
• Monitor deliveries to ensure timely receipt and intervene if reshipping is necessary.
• Participate in departmental Quality Assurance/Quality Improvement activities, dedicating at least 2% of time, with increased participation as needed.
• Interact with co-workers and visitors in line with Jefferson's iSCORE values.

Other Functions and Competencies

• Act as liaison between patients and insurance companies, foundations, and manufacturers.
• Understand billing processes for commercial, Medicaid, and Medicare coverage.
• Demonstrate active listening, relationship-building, and trust with patients and providers.
• Respond compassionately to customer inquiries.
• Manage multiple issues simultaneously.
• Resolve complex customer conflicts independently.
• Document issues and recognize trends.
• Possess knowledge of medical terminology, insurance processes, HIPAA, and patient rights.
• Utilize software and technology effectively for customer interaction.
• Support customer inquiries and resolve problems promptly.

Work Details

Workday: Day shift (United States of America)

Worker Sub Type: Regular

Location

3500 Horizon Drive, King of Prussia, PA, USA

About Jefferson Health

Jefferson, with over 65,000 staff, is dedicated to high-quality clinical care, community health, professional education, and research. It includes Thomas Jefferson University and Jefferson Health, serving through numerous hospitals and outpatient locations in the Philadelphia region and beyond. Jefferson Health Plans offers broad health coverage options in PA and NJ. Jefferson values diversity and equal opportunity employment.