Licensing and Payors Specialist

• Support our Care Teams in being a patient advocate to gain insurance coverage for prescribed therapies or assist in resolving other insurance-related issues
• Complete and submit applications for pharmacy, 3PL, and wholesale licenses.
• Complete, submit, and track Medicaid and Medicare provider applications.
• Keep all pharmacy/wholesale licenses and Medicaid/Medicare status current.
• Address any claim discrepancies from Care Teams.
• Compile, submit, and track internal payer desk audits.
• Act as primary contact for payer on-site audits.
• Monitor government entities for regulatory updates and/or changes.
• Set up Contracted Pharmacies for brick-and-mortar states.
• Support new program implementations as appropriate.
• Manage ongoing maintenance and testing of facilities and equipment.
• Serve as a mentor for new team members.
• Assist with Board of Pharmacy correspondence.
• Assist with correspondence to payers concerning audits or claim issues.
• Help maintain QA processes and implementation.
• Assist the Training Specialist in training new team members on specific functions and tasks.
• Other duties as needed or assigned by the business.

• A high school diploma or GED is required.
• 2 or more years’ experience with medical/pharmacy insurance verification, including benefit investigation.
• Knowledge of Medicare and Medicaid billing.
• Proficient in Microsoft Office Suite, specifically Excel, Word, PowerPoint, and Outlook
• Experience with prior authorization and SMN preparation.
• Excellent verbal, written, organizational, and judgment skills.
• Knowledge of claim appeals and medical terminology is required
• Knowledge of medical/pharmacy insurance benefit language; i.e.. EOB’s, deductibles, out-of-pocket, co-insurance, co-pays, etc.
• Ability to work independently, with limited supervision.
• Ability to define CMS 1500’s, provider numbers, CPT, HCPC’s, ICD9, NCPDP and NDC codes/numbers.
• Patient Assistance Program knowledge a plus.
• Excellent written and verbal communication and interpersonal skills.
• Ability to motivate teams to produce quality materials within tight timeframes and simultaneously manage several projects.
• Ability to participate in and facilitate group meetings.
• Willingness to work a flexible schedule.

Optime Care provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.