Copay Support/Claims Processing Specialist

About This Role

This role is responsible for servicing inbound calls and communications related to copay support and claims processing, acting as a critical point of contact for various stakeholders. The specialist will adjudicate, troubleshoot, and process medical and pharmacy claims, ensuring proper payment processing and data integrity.

Responsibilities

• Service inbound calls, EOB faxes, and mail from pharmacies, patients, Sites of Care, Health Care Providers, and copay vendors
• Engage with pharmacy claim adjudicators, third party medical claim administrators, merchant vendors, and finance for manual claim reimbursement
• Adjudicate, troubleshoot claim rejections, claim reversals, and allocation deficiencies
• Identify group accumulator and maximizers and provide alternate payment processing methods
• Handle paperwork related to medical procedures, treatments, and services for approval, denial, or pending determination
• Manage claim appeal handling and ensure quality control of commercial copay programs
• Collaborate with internal HUB teams on enrollment discrepancies and partner with claim adjudication vendors
• Monitor and remediate medical and pharmacy manual data entry errors
• Serve as Subject Matter Expert for internal and external stakeholders on copay claim adjudication issues and platform logic
• Act as primary point of contact for inquiries from prescribers, patients, external clients, and internal program team members

Requirements

• High school diploma or GED
• Computer skills: Contract Management Systems, Microsoft Office
• Other skills: Pharmacy Data Management (PDMI), PNC Card Platform

Qualifications

• High school diploma or general education degree (GED), or Associate's Degree (AA) or equivalent from a two-year college or technical school
• One to three months related experience and/or training, or six months to one year related experience and/or training

Nice to Have

• Associate's Degree (AA)

Skills

* Required skills

Benefits