The Pharmacy and Resolution Claims Specialist is responsible for the processing and completion of resolution files and maintains regular contact with claimant attorneys, claimants, adjusters, defense attorneys and physicians as required. This position acts as a liaison between parties and ensures all Action Plans & Progress Reports are completed at the highest level of quality and in compliance with all company policies and procedures.
ESSENTIAL DUTIES AND RESPONSIBILITIES TO PERFORM THIS JOB SUCCESSFULLY INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:
• Review MSA reports, medical records, prescription history, claims payment history and legal documents to identify issues and develop a plan of action (POA) on an ongoing basis.
• Communicate action plans to resolve and, if indicated, get approval to proceed with contact to any necessary parties (i.e. defense attorney, claimant, claimant attorney and/or treating doctor) and to facilitate appropriate resources for case resolution.
• Work with defense attorney, claimant attorney or claimant in addressing resolution issues.
• Develop written correspondence and/or communicate via phone, fax or email with the client, attending physician, peer reviewer, Medical Director or Medical Advisory Panel, claimant/claimant attorney or any other pertinent party including internal parties such as the Account Executive.
• Reviews all new documentation received to determine the conclusion of service, and facilitates updating the MSA Report with the File Coordination team, when needed.
• Review, understand, and consider Client Handling Protocols (CHP).
• Ensures appropriate documentation of referrals including system notes and emails.
• Promotes effective and efficient utilization of clinical resources and supplies.
• Abide by all rules of the company such as safety, confidentiality and organizational directives.
• Ensures all federal CMS requirements and/or state mandates are adhered to at all times.
• Provides insight and direction to management on report quality and compliance with all company policies and procedures, client specifications and CMS guidelines.
• Participate in various educational and/or training activities, as required.
• Perform other duties as assigned by management.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Minimum 2 years of experience preparing and/or handling of Medicare Set-Asides including submission of MSAs to CMS and/ or; 2-3 years of Workers Comp claims/managed care experience.
• Must be able to adequately operate a general computer, fax, copier, scanner, and telephone.
• Must have strong knowledge of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Ability to demonstrate strong customer service skills.
• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Ability to follow instructions and respond to managements’ directions accurately.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Ability to concentrate and multitask in a fast paced work environment.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must be able to maintain confidentiality.
• Must be able to demonstrate and promote a positive team -oriented environment.
• Must be able to work well under pressure and/or stressful conditions.
• Must possess the ability to manage change, delays, or unexpected events appropriately.
• Must possess excellent skills in English usage, grammar, punctuation and style.
• Demonstrates reliability and abides by the company attendance policy.
• Must maintain a professional and clean appearance at all times consistent with company standards.
EDUCATION AND/OR EXPERIENCE
• High school diploma or equivalent required, bachelor’s degree preferred.
• Minimum 2 years of experience in one of the following fields required:
• Medical or Pharmaceutical
• Medicare Secondary Payer
CERTIFICATES, LICENSES, REGISTRATIONS
• MSCC Certification Preferred