Pharmacy Insurance Coordinator

Role Overview

Pharmacy Insurance Coordinator at King's College Hospital London. This role manages insurance claims, authorizations, and reconciliation for pharmacy services within the hospital environment.

Role Purpose

To ensure accurate and timely processing of insurance claims, maintain compliance with regulatory standards, and coordinate with internal and external stakeholders to minimize claim rejections and optimize revenue cycle management for pharmacy services.

Key Responsibilities

Supervision and Compliance

• Work under the supervision of the immediate manager.
• Comply with all the latest Joint Commission International (JCI) and Dubai Health Authority (DHA) government standards.

Insurance Knowledge and Claims Submission

• Demonstrate complete knowledge of insurance policies and protocols.
• Submit claims and approvals accurately.
• Analyze electronic claims (E-Claims) prior to submission to insurance companies.
• Conduct E-Claims analysis prior to submission to insurance companies by Finance.

Claims Monitoring and Authorization

• Monitor the pending list on a daily basis.
• Follow up on insurance approvals on a daily basis.
• Monitor and follow up on prior electronic authorization for services.
• Monitor and follow up on prior electronic authorization for outpatient and inpatient services.

Claims Reconciliation and Coordination

• Perform electronic reconciliation of claims paid and outstanding with insurance companies and coordinate with Revenue Cycle Management (RCM) and Finance.
• Coordinate with appropriate personnel to ensure that all formalities agreed with insurance companies are followed to minimize objections and avoid delays in clarifications, including coordination with Patient Relations, Nursing, Physicians, and Finance.

Rejections and Problem Solving

• Answer insurance queries, analyze rejections, and process claim re-submissions.
• Work to avoid and minimize claim rejections.
• Identify and analyze problems, take action to resolve, apply sound judgment, and take responsibility for their resolution.

Billing and System Management

• Ensure all invoices and claims are captured on the pharmacy/hospital billing system.

Communication and Work Ethics

• Prioritize accurate, thorough, and appropriate work.
• Inform and influence others through clear, concise expression of ideas and information in verbal and written communication.

Organizational Responsibilities

• Perform any additional duties reasonably assigned by the organization or line manager to meet operational needs and support specific objectives of your department and organization.
• Comply with all organizational and departmental policies, procedures, legal requirements, and applicable regulations at all times, and take personal responsibility to read, understand, follow, and keep updated with the latest versions.
• Avoid and report any actions that may cause financial loss, reputational damage, or breach of trust to the organization, including fraud, dishonesty, or misrepresentation, which may result in disciplinary action, termination, and legal liability.
• Maintain confidentiality of all organizational, patient, client, and employee information in accordance with policies and laws.

Qualifications & Experience

• Bachelor's Degree in pharmacy, nursing, or any related medical field preferred.
• Minimum 2 years prior experience in a similar role within a healthcare organization.
• Preferred experience in patient billing and pre-authorization in hospital or day care settings.

Skills & Competencies

• Awareness and understanding of King's College Hospital (KCH) policies and initiatives.
• Support quality patient care by showing empathy, maintaining patient dignity, and following proper protocols.
• Support and guide junior team members, offering advice and assistance if required.
• Handle sensitive information with a high level of confidentiality and discretion, ensuring compliance with organizational policies and regulatory requirements.
• Proficiency in basic computer applications, including MS Office (Word, Excel, PowerPoint, Outlook), with the ability to manage digital documentation and communication effectively.
• Excellent verbal and written communication skills to collaborate effectively with multidisciplinary teams, patients, and stakeholders.
• Highly self-motivated with strong internal work standards; set realistic goals for self and support others in achieving team objectives.
• Flexible and adaptable to changing priorities, ensuring goals are met in dynamic environments.
• Strong problem-solving skills with the ability to manage unexpected issues and identify when to escalate.
• Maintain professional and personal credibility across all staff groups.
• Demonstrate the ability to manage multiple tasks efficiently in a fast-paced work environment.