Reimbursement Specialist

Job Description

THE POSITION: The Reimbursement Specialist is primarily responsible for interfacing with patients, HCPs and payers by providing reimbursement support for benefit coverage, prior authorization, claim denials, appeals, triage to third‑party support centers, and general inquiries.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Provide dedicated and personalized support delivered over the phone, CRM, and email.
• Complete investigations and answer questions regarding insurance benefits, coverage and out‑of‑pocket costs.
• Assist with prior authorization and medical necessity processes, benefit verification and assistance in a manner consistent with industry best practices.
• Determine when a call reason is best handled by a third‑party support center and triage accordingly.
• Maintain a positive attitude and a helpful approach to customers and clients.
• Conduct enrollment intake for all incoming inquiries.
• Participate in continuous quality improvements and training opportunities.
• All other duties as assigned.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.

EXPECTATIONS OF THE JOB:

• Assist callers with benefit verifications and support related to coverage, out‑of‑pocket costs, and prior authorizations as needed.
• Triage to appropriate third‑party support centers.
• Focus on results in a professional, ethical, and responsible manner when dealing with patients, caregivers, customers, vendors, team members, and others.
• Accept accountability and responsibility in work practices and deliver on promises.
• Foster a collaborative, team‑oriented attitude and communicate effectively with clarity and transparency.
• Use innovative critical and creative thinking to evaluate and solve work and customer issues.
• Seek assistance in solving work problems through collaboration and information seeking.
• Learn, understand, and follow all company and client policies and procedures.
• Must be able to work rotating 8‑hour shifts Monday through Friday.

MINIMUM

KNOWLEDGE, SKILLS AND ABILITIES:

• Strong pharmacy reimbursement experience, especially understanding of the prior authorization process.
• Experience conducting benefit verifications with payers, preferably supporting retail prescription drug products.
• Knowledge of healthcare administration and specifically healthcare billing and reimbursement procedures and regulations.
• Knowledge of retail pharmacy operations preferred.
• Excellent oral, written, and interpersonal communication skills.
• Ability to multi‑task.
• Accurate and detail‑oriented.
• Ability to work independently and function as a team player.
• Ability to work in a fast‑paced, metric‑driven environment while remaining patient‑minded.
• Strong computer skills with a working knowledge of Microsoft Word, Excel, and PowerPoint.

PREFERRED QUALIFICATIONS:

• Customer service and/or contact center experience.
• Reimbursement/Patient Services experience.

PHYSICAL/MENTAL DEMANDS AND WORKING ENVIRONMENT:

The physical and mental requirements include frequent reaching, grasping, standing, sitting, walking, talking, and hearing. The employee may be required to lift up to 25 pounds. The noise level is usually moderately quiet with frequent interruptions and multiple demands.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, veteran status, or any other protected characteristic.

Consistent with the Americans with Disabilities Act (ADA) and applicable state and local laws, EVERSANA provides reasonable accommodation when requested by a qualified applicant or candidate with a disability, unless such accommodation would cause undue hardship. The policy applies to all aspects of the hiring process. For accommodation requests, please contact us at [email protected].