Pharmacy Claims Lead

Profile

Description

The Pharmacy Claims Lead operationalizes and monitors Coordination of Benefits (COB) and subrogation claim processing logic and processes. Exercises independent judgment and decision making on managing staff, complex issues regarding job duties and related tasks, and works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action.

Responsibilities

Responsibilities


Lead a team of Pharmacy Professionals responsible for production oversight and testing of COB and subrogation pharmacy claim functions in the SS&C Pharmacy Solution Point-of-Sale (POS) system
Empower Associates and elevate their voices
Associate engagement and Cultural Competency
Enable personal & professional growth
Develop analytics and reporting needed to support the day-to-day business
Actively identifies and owns process improvements and operates with a high level of personal accountability
Productivity reporting to aid in ensuring that the organizational goals are met
Manage activities related to implementation, monitoring and support of Commercial, Medicare and Medicaid business
Ensure compliance, Federal & State, and engage in external/internal audits
Quality reporting to ensure legislative and process adherence
Develop and document processes. Write and maintain policies and procedures; while ensuring policies and procedures address compliance and regulatory requirements
Effectively collaborate with other Humana departments and Pharmacy Claim Operations teams
Reporting, metrics and trend for pharmacy POS activities
Has expertise in systems and technologies to lead team to increase performance and capabilities while understanding impacts
Additional projects assigned, based on business needs


Required Qualifications


3-5 years of Medical/Pharmacy Claims experience
Prior demonstrated experience with leading end to end process improvement or process design and implementation roles
Working knowledge of all Microsoft Office applications (Word, Visio, Excel and Access) and SQL
Strong consultative skills and relationship building skills
Excellent written and verbal communication skills
Excellent planning and organizational skills
Ability to work on multiple projects
Ability to successfully handle change in a fast paced environment


Preferred Qualifications


Demonstrated strong leadership skills (as defined by informal or formal leadership experience)
Bachelor's Degree or equivalent experience in the health insurance industry
Project Management experience


Scheduled Weekly Hours

40

Company info

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