Specialty Clearance Specialist - Intake

Accountabilities: • Process new patient referrals by verifying insurance eligibility, reviewing coverage, and coordinating benefits across multiple insurance plans.

• Perform benefit verifications for medications, administration supplies, and related infusion services, ensuring all coverage details are accurately documented. • Review and document copayments, coinsurance, deductibles, prior authorization requirements, and other relevant reimbursement information. • Run test claims and calculate estimated patient out-of-pocket expenses using insurance benefit information, payer contract fee schedules, and applicable self-pay pricing. • Initiate, prepare, submit, and follow up on prior authorizations, predeterminations, and medical review requests to secure the necessary payer approvals. • Review and obtain clinical documentation required for authorization submissions and reimbursement processes. • Communicate referral status, insurance coverage, authorization updates, and other relevant information to patients, referral sources, and internal and external stakeholders. • Identify patients who may need financial assistance and facilitate enrollment in manufacturer copay assistance programs or charitable foundations. • Generate new patient start-of-care documentation and ensure accurate completion of intake paperwork. • Maintain compliance with applicable healthcare privacy regulations and established operational procedures while meeting productivity and quality expectations.

Requirements:

• High school diploma or equivalent. • At least 2 years of experience in home infusion or specialty pharmacy intake, with hands-on experience in prior authorizations, insurance benefit verification, test claim adjudication, and HCPCS calculations. • Working knowledge of Medicare, Medicaid, and managed care reimbursement guidelines. • Ability to interpret payer contract fee schedules using National Drug Codes (NDC) and Healthcare Common Procedure Coding System (HCPCS) units. • Experience reviewing insurance coverage, calculating patient financial responsibility, and managing authorization requirements. • Knowledge of HIPAA regulations and the importance of maintaining patient confidentiality. • Basic proficiency in Microsoft Excel and Word. • Familiarity with CPR+ is considered an advantage. • Strong organizational and multitasking abilities, with the capacity to manage multiple referrals and competing priorities while maintaining accuracy and productivity. • Excellent communication and interpersonal skills, with the ability to interact professionally with patients, healthcare providers, and internal teams. • Ability to work independently in a fast-paced, deadline-driven environment while demonstrating attention to detail and accountability. • Availability to work Monday through Friday, from 9:00 AM to 5:30 PM Eastern Time.