Quality Control Coordinator

Job Description

CSI Pharmacy is hiring a Quality Control Coordinator to join our dynamic team. CSI Pharmacy is a nationwide specialty pharmacy, founded by pharmacists and dedicated to providing services for patients with chronic and rare illnesses that require complex care. This role will be based out of the Dallas, TX area.

This position will be responsible for reviewing the quality of work produced by the referral management and intake teams. Information and materials generated from these departments will be sent to the Intake Director and Quality Control Manager for final review. This role will include, but not be limited to, verification of customer insurance, healthcare claim submissions, PDP and Medical prior authorizations, and other related work produced.

Essential Duties and Responsibilities

• Reviews insurance operational areas:

• Insurance Verification and entry into Care Tend

• Prior Authorization Processing

• Claim Submission

• Intake Workflow

• Copay Assistance / foundation openings

• Insurance software

• Processes, policies, and procedures creation, maintenance, and updates

• Responsible for ensuring all payer audits (Commercial, PDP, and Government) are addressed and responded to as appropriate by the Quality Control team.

• Acts as Insurance/Medical Record Specialist

• Ensures Insurance/Medical Records Team actions are in accordance with applicable Medicare, State, and Federal Guidelines

• Communicates with the Intake Director on improvements and areas of opportunity to streamline operations in all functional areas.

• Ongoing Communication with Referral Management, Billing, Insurance Verification, and Data Entry.

• Assists in appropriate product selection by understanding all payers, reimbursement, and formularies.

• Reviews and assists with developing Intake and Insurance Verification Policies that affect departmental procedures.

• Consistently represents the company in a professional manner. 

• Maintains effective working relationships and cooperates with all personnel in the Company.

• Adheres to the Company’s compliance requirements as stated in the policy and procedure manual and all other related policies.

• Performs other duties and responsibilities as assigned. This may include, but is not limited to, policy creation at the direction of the intake director.

Qualification Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Provides the highest level of professionalism, responsiveness, and communication to build and maintain the maximum customer base possible.

• Possesses the ability to multi-task and frequently change direction as required.

Education and/or Experience

• A High School Diploma or equivalent GED is required, at minimum. College or technical college preferred.

• 3 - 5 years medical experience.

• Ability to work independently and within a multidisciplinary team. 

• Minimum two years in healthcare environment

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, climb stairs, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

The employee frequently lifts and/or moves up to 20 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This job generally operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax machines. While performing the duties of this position, the employee may travel by automobile and be exposed to changing weather conditions.

Comments

This description is intended to describe the essential job functions, the general supplemental functions, and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities, and requirements of a person so classified. Other functions may be assigned, and management retains the right to add or change the duties at any time.

NOTICE: Successful completion of a drug screen prior to employment is part of our background process, which includes medical and recreational marijuana.

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By submitting your application, you are confirming that you are legally authorized to work in the United States.

JR# JR238326