The Copay Support/Claims Processing Specialist is a critical role within the organization and is responsible for servicing inbound calls, EOB faxes, and mail (emails, USMail) from pharmacies, patients, Sites of Care, Health Care Providers, copay vendors (PDMI, FHA and Merchant Card processors) and other sources. Required engagement is with pharmacy claim adjudicators, third party medical claim administrators, merchant vendors, finance for manual claim reimbursement, Sites of Care and Health Care Providers.
The Copay Support/Claims Processing Specialist will adjudication, troubleshoot claim rejections, claim reversals, allocation deficiencies, identifying group accumulator and maximizers, provide alternate payment processing method, handle paperwork related to medical procedures, treatments and services submitted by the site of care or health care providers that meet the program business rules for determination of approval, denial, or pending for submission of required information for final determination as well as claim appeal handling.
- Quality control of commercial copay programs.
- Collaborate with internal HUB teams on enrollment discrepancies (missing info and duplicates)
- Partners with claim adjudication vendors ensure proper claims processing and data integrity.
- Monitor and remediate medical and pharmacy manual data entry errors
- Serve as Subject Matter Expert for internal and external stakeholders on medical and pharmacy Copay claim adjudication issues and platform logic variations.
- Provide ongoing insights on specific program trends and system/process opportunities.
Patient and Prescriber Support:
- Act as the primary point of contact for handling inquiries from prescribers, patients, external clients, and internal program team members.
- Subject Matter Expert on reviewing and processing of medical claims submitted for copay programs where the therapy is primarily processed through a medical benefit
- Thorough understanding of copay program design and elements eligible for payment processing
- Ensure proper CMS form and EOB is provided for each eligible item
- Validate required elements for payment approval are present
- If not partner with HUB to secure missing information
- Create manual medical reimbursement record for submission to finance
- Review Directive Analytics against Net-Suite and make necessary corrections
- Identify applicable programs and guide stakeholders through next steps for patient support.
- Accept inbound calls, team chats, and emails. Ensure one-call resolution for patients and providers.
- Communicate status updates across all patient support activities in a holistic, clear, and professional manner.
- Liaise with program-specific AssistRx resources to secure outcomes and resolve escalations.
- Maintain accurate documentation and ensure protection of patient and prescriber information.
