Specialist RCM - Quality Validation MM - Remote

Job Summary

Responsible for validating patient orders, performing quality assurance with items to be shipped, monitors pre‑shipment procedures and coordinates distribution review. Assists with meeting Revenue Cycle Management goal targets by understanding the verification process, the logistics process and working with J‑Codes, diagnosis codes, route of administration, place of service, IPA claims, Medicare B & D billing, Major Medical and PBM.

• Utilizes all available resources to review and verify pre‑shipment information for ordered items; verifies patient insurance coverage and completes a full Medical Verification of medications, administration supplies, and related pharmacy services through proper investigation into either major medical benefits or pharmacy benefits.
• Investigates prior authorization and any other claim rejections.
• Audits Major Medical claims for accuracy and documents findings for quality improvement initiatives.
• Acts as subject matter expert in completing a full Medical Verification for all medications, administration of supplies and related pharmacy services and pre‑shipment procedures.
• Communicates with other departments and senior managers as necessary to facilitate urgent needs.
• Enhances review of high‑risk referrals.
• Reviews patient A/R prior to completing referral audit.
• Other responsibilities as judgment or necessity dictates.

• High school diploma from accredited school or equivalent GED.
• At least 2 years' work experience in pharmacy benefit or medical benefit insurance billing, and/or providing customer service to team members and external customers, including meeting quality standards for services, and evaluation of customer satisfaction.
• Good verbal and written communication and interpersonal skills with the ability to communicate in a diplomatic and confidential manner.
• Strong initiative with the ability to work in a team environment; organized and detail oriented with proven problem‑solving skills.

• Associate's Degree in healthcare, business, or related area of study.
• Relevant work experience in a Specialty Pharmacy, PBM and Major Medical.

We will consider employment of qualified applicants with arrest and conviction records.

The Salary below is being provided to promote pay transparency and equal employment opportunities  actual hourly salary within this range that you will be offered will depend on a variety of factors including geography, skills and abilities, education, experience and other relevant factors. This role will remain open until filled. To review benefits, please copy and paste this URL into your browser