Senior Reimbursement Specialist - Specialty Pharmacy

This role works directly with healthcare and pharmaceutical providers, as well as insurance plans/payers to gather information about a patient’s insurance and the coverage provided for a specific pharmaceutical product. You will support the healthcare providers addressing questions regarding coding and billing and navigating complex reimbursement issues.

Key Responsibilities:

Patient Account Management

Research and update patient records with:

• Full demographics
• Financial and insurance information
• Provider and facility details
• Prescription data
• Patient and provider signatures (as required)
• Ensure all documentation is accurate and up to date in Salesforce.

Summary of Benefits (SOB) Review

Confirm eligibility and benefits by reviewing the Benefit Investigation Report (BIR) and the SOB and determine:

• Whether a manual BI was completed
• If the SOB was generated using the correct template
• Revise and finalize the SOB documentation.
• Fax the completed SOB to the Health Care Provider’s (HCP) office and follow up, as needed.
• Notate the account and complete associated tasks in Salesforce.

Call Handling (Inbound/Outbound)

• Verify HIPAA before proceeding (Name, DOB, ZIP, APA number).
• Provide one-call resolution whenever possible
• Answer inquiries
• Address concerns
• Research and update account information
• Give accurate status updates
• Leave voicemails for HCPs/Points of Contact when unable to reach directly.

FRM Collaboration

• Communicate via phone, email, or scheduled Microsoft Teams meetings.
• Work with Field Reimbursement Managers to align on provider-specific needs or issues.
• Provide timely updates or assistance based on FRM feedback or directives.

Administrative Tasks

Perform daily reviews of:

• Salesforce tasks (past due and open)
• Email inbox
• Microsoft Teams messages
• Calendar for meetings or deadlines
• ACE-specific or territory-specific shared spreadsheets (SharePoint)
• Conduct monthly PAP audits to verify accumulations and insurance coverage accuracy, when applicable

Financial Assistance (FA) Support

• Review Enrollment Form (EF) for service selections.
• Initiate or advance FA case stages appropriately.
• Collect and process all required documentation.
• Engage in PAP/Copay chat channels to coordinate with subject matter experts.
• Submit documentation to the pharmacy via file drop.
• Fax or upload FA approval or denial letters to the HCP.
• Coordinate with the FRM for any provider-specific FA expectations or guidelines.

Required Skills & Qualifications:

• Strong knowledge of benefit verification and financial assistance programs.
• Experience with Salesforce or equivalent CRM tools.
• High attention to detail and task completion accuracy.
• Effective communication via phone, email, and collaboration tools (Teams).
• Ability to manage high-volume caseloads with time-sensitive responsibilities.
• Familiarity with HIPAA regulations and patient confidentiality standards.

Requirements

• QUALIFICATIONS:
• College degree is preferred or high school diploma; equivalent combination of education and experience is also considered.
• Other skills required: 
• Previous work experience in Medical and Pharmacy Reimbursement or Customer Service.
• Submitting billing data to appropriate insurance providers
• Processing claims and resolving denial instances.
• Achieving maximum reimbursement for services provided
• Completing Medicare, Medicaid and Commercial insurance claim submission.
• Documenting and reporting payment information.
• Professional level skills in computer use, including but not limited to Microsoft Office, email, web-based applications, and keyboard skills.
• Demonstrated strong written and verbal communication skills with providers, patients and insurance companies.
• Interpersonal skills to facilitate work with a wide range of individuals and groups from culturally diverse publics.
• Problem solving skills.

COMPETENCIES:

Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.

Customer Service - Manages difficult or emotional customer situations; Res