Coverage Determination Representative

Job Description

The Coverage Determination Rep I is responsible for gathering all information required on an authorization, completing, and submitting the authorization form to insurance company and for all follow up phone calls and documentation of these authorizations.

Responsibilities

• Obtain prior authorizations; initiate requests, track progress, and expedite responses from insurance carriers and other payers.

• Review prescription for accuracy of prescribed treatment regimen prior to submission of authorization.

• Gather all necessary information from prescriber offices to complete authorization forms.

• Notifying appropriate staff of approved/denied medications.

• Process/reverse online claims to confirm authorization outcome.

• Completes status check with insurance company regarding receipt and outcome of prior authorization. 

• Perform call to prescriber office for status of authorization or request for additional information.

• Responsible for all documentation of authorization statuses into CPR+ progress notes.

• Update sales staff with pertinent information.

• Participate and perform other duties as assigned by leadership

Skills & Abilities

• Positive Attitude

• Professional appearance

• Work cooperatively and be a liaison between departments when needed

• Knowledge of standard medical terminology and pharmacy prior authorization and appeal/denial processes desired

• Demonstrate excellent oral, presentation, and written communication skills

• Demonstrate proficiency in the use of MS Office software, which includes Excel, Word, and Outlook

• Demonstrate the BioPlus C.A.R.T. values.

Qualifications

• High School Diploma or Equivalent.

• At least 1 year experience working with pharmacy prior authorizations, or pharmacy billing.

• Specialty pharmacy experience preferred.

Qualifications

Additional Information

BioPlus offers competitive compensation packages including health care, 401(k), growth potential, and a challenging and exciting work environment. 

BioPlus is an Equal Opportunity Employer