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

Humana Inc.
Website : http://www.humana.com