Officer - Insurance Approval

The Insurance Approval Officer is responsible for managing and processing insurance claims, ensuring approval for medications and treatments prescribed by healthcare professionals in the pharmacy department. This role involves coordinating with insurance providers, pharmacists, and healthcare teams to facilitate prompt approvals for patients’ prescriptions, ensuring compliance with insurance policies, and enhancing the patient care experience.

Insurance Verification: Verify patient insurance details and coverage for prescribed medications and treatments.

Claims Processing: Prepare and submit insurance claims for medication approvals, ensuring accuracy and compliance with insurance guidelines.

Authorization Requests: Communicate with insurance companies to request prior authorizations for medications and treatments, providing necessary documentation.

Follow-Up: Follow up with insurance providers on pending approvals, denials, or requests for additional information.

Patient Communication: Inform patients and healthcare providers of the status of insurance approvals or denials, and assist in finding alternative solutions if necessary.

Documentation: Maintain detailed records of insurance communications, approvals, and rejections for compliance and reporting purposes.

Collaboration: Work closely with pharmacists, healthcare providers, and insurance representatives to resolve issues related to medication approvals.

Policy Knowledge: Stay up to date with insurance policy changes, formulary updates, and regulatory requirements related to pharmacy services.

Appeals Management: Assist in the preparation and submission of appeal documentation for denied claims and work with insurance providers to resolve issues.

Education: High school diploma or equivalent required; Associate’s degree in health administration, pharmacy technology, or related field preferred.

Experience: Minimum of 2 years of experience in insurance claim processing, preferably within a healthcare or pharmacy setting.

Knowledge: Familiarity with insurance policies, pharmacy procedures, and prior authorization processes.

Skills:

Strong communication and customer service skills.

Attention to detail and strong organizational abilities.

Ability to work independently and collaboratively in a fast-paced environment.

Proficiency in using insurance software and electronic health record (EHR) systems.