Pharmacy Claims Professional 2 Remote

Profile

Description

The Pharmacy Claims Professional 2 is responsible for the day to day operations of accumulator processing, providing investigative responses to various audit activity, and developing and maintaining guidelines.

Responsibilities

The Pharmacy Claims Professional 2 analyzes and answers inquiries regarding pharmacy claims adjudication, including method of payment, co-pay or deductible amounts, and/or reason for denial. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Responsibilities


Understanding and performing day to day operations as it relates to accumulator processing; to include investigation and trouble-shooting of various accumulator reports
Designs and participates in the execution of analytical projects requiring multi-faceted data and provide recommendations regarding customer issues, including the involvement of other team members as needed
Compliance activities related to all Lines of Business. This includes documentation of policy and procedures, and attestation documentation for Medicare.
Coordination and development of responses for all audit inquiries; Internal audit, CMS audit, Department of Insurance inquiries, etc.
Development and maintenance of departmental guidelines and processes
Activities associated with monthly releases for both Humana and our Pharmacy Benefit Partner
Responsible for the coordination of work between Humana and our Pharmacy Benefit Partner.
Daily interaction with various internal departments such as CAS and MTV Integration teams, CAS IT, Corporate Compliance, Corporate Pharmacy, Internal Audit, PBM Compliance and Risk Management, HPS Operations Finance.


Required Qualifications


Bachelor's Degree or equivalent work experience
Prior group health insurance experience
Strong analytical and problem solving skills
Ability to handle changing priorities yet maintain processes, projects and composure
Ability to work in fast paced, dynamic and changing environment while managing multiple projects simultaneously
Excellent communication skills, both oral and written, and ability to adapt your communication style for the audience
Strong attention to detail
Comprehensive knowledge of all Microsoft Office applications, including Microsoft Word, Excel, Outlook and PowerPoint


Preferred Qualifications


Previous experience with pharmacy benefits management
Claims experience
Knowledge/experience working with SharePoint and Power BI applications
Prior work history in a clinical, pharmacy or related setting


Additional Information

Scheduled Weekly Hours

40

Company info

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