Pharmacy Claims Rep 2

Profile

Description

The Pharmacy Claims Representative 2 adjudicates pharmacy claims and process pharmacy claims for payment. The Pharmacy Claims Representative 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.

Responsibilities

The Pharmacy Claims Representative 2 analyzes and answers inquiries regarding pharmacy claims adjudication, including method of payment, co-pay or deductible amounts, and/or reason for denial. Decisions are typically focus on interpretation of area/department policy and methods for completing assignments. Works within defined parameters to identify work expectations and quality standards, but has some latitude over prioritization/timing, and works under minimal direction. Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion.

Essential Duties and Responsibilities:


Assist in setting up and maintaining hospice/facility/pharmacy relationships under the direction of the Pharmacy Claims (Support Services) Manager and the Director of Support Services
Assist pharmacies with claims adjudication
Complete incoming tasks as assigned by the Pharmacy Claims (Support Services) Manager
Obtain all necessary information for facilities and their related pharmacies
Assist the Call Center management team with projects to enhance the workflow and success of the Call Center
Assist Customer Service team with claims research/resolution


RESPONSIBILITIES (include but are not limited to):

Billing:


Assist pharmacies with claims adjudication by adjusting/correcting authorizations in dispensing systems and PBM systems
Ensure timely adjudication of prescription claims through PBM systems
Contact hospices for authorizations/approvals for submitted claims where necessary
Ensure accuracy of patient profile data including related/not related status, authorization status, etc
Research and correct pharmacy invoices from hospices
Understand formulary and billing platform differences (PD vs. FFS) from hospice to hospice
Assist Customer Service team with claims research/resolution via dispensing systems, PBM systems and fax systems
Evaluate compound claims for proper ingredients/qtys/cost and ensure timely claims adjudication
Research claims for hospice/pharmacy audits


New Hospice Start-Ups:


Complete assigned facility/pharmacy spreadsheet by contacting both the facilities and pharmacies to verify accuracy of all information provided
Coordinate all information for facility pharmacies including verification of PBM systems
Update facility pharmacy spreadsheets and implementation team members on the progress with these pharmacies
Communicate with the facility pharmacies on proper billing procedures and contact information for rejected claims


New Facilities:


Gather partial information from Call Center on facilities not listed and obtain correct information to be entered into the database
Link facilities to their respective hospices once all information is obtained.
Assist with Confirmation Fax reports to update facility and pharmacy relationships and demographic information


Required Qualifications


High School Diploma
Less than 2 years of technical experience
Less than 5 years of data analysis & problem solving skills
Comprehensive knowledge of all Microsoft Office applications, including Access, Word, Excel and PowerPoint
Strong verbal and written communication skills, including the ability to tailor communication to audience
Strong organizational and time management skills
Ability to handle multiple tasks, meet deadlines, and follow-up timely
Must be passionate about contributing to an organization focused on continuously improving consumer experiences


Preferred Qualifications


Call center experience
Previous experience with pharmacy benefits management
Claims experience and claims adjudication experience
Knowledge/experience working with SQL (via MS SQL Server, Oracle, PL/SQL or other)
Pharmacy Tech experience


Additional Information

Scheduled Weekly Hours

40

Company info

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