laughingdaisy

 Obtained requests from provider or pharmacy via fax, provider portal or service form inquiry. May obtain requests from provider or pharmacy by phone in some areas of the organization. Use multiple software systems and various resource sites to determine member plans and requirements. Gather all required documentation including verification of benefit eligibility. Build cases in the utilization management system.  Used knowledge of process and judgement to evaluate identified cases that require additional notification to member, provider, and/or pharmacist. At times, outreach to providers and/or pharmacists may be required to obtain additional information.  Ensured accuracy of data entry to prevent compliance and/or downstream process issues.

Worked rejected pharmacy claims. • Called insurance companies and pharmacies in order to get a paid claim. • Called LTC homes for new admissions and entered new LTC patients into system. • Would also help out in pharmacy area to pull medications to be filled • Performed some data entry also