Pharmacy Claims Representative

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

This is a work at home position.

                                 

Assist local pharmacies with claims adjudication to support medication access for HC & LTC hospice patients; reconcile historic billing issues.

Essential Duties and Responsibilities:

• Assist in setting up and maintaining hospice/facility/pharmacy relationships under the direction of the Pharmacy Claims Team Leaders & the Pharmacy Claims (Support Services) Manager
• Assist pharmacies with claims adjudication
• Complete incoming tasks as assigned by the Pharmacy Claims Team Leaders and 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
• Demonstrate basic understanding of Enclara Pharmacia standard/custom formularies
• 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.

Qualifications:

• Strong verbal and written communication skills, including the ability to tailor communication to audience.
• Self-motivated, organized
• Strong attention to detail
• Team player
• Problem-solving skills and ability to follow through on tasks assigned
• Ability to handle multiple tasks, meet deadlines, and follow-up timely.

Required Education and/or Experience:

• 1+ years of Pharmacy Technician experience
• Strong knowledge working with pharmacy claims judication

Preferred Experience:

• PBM experience
• Dispensing system experience
• CPhT or EXCPT
• Drug knowledge
• High school diploma

Schedule:

Monday-Friday 2:30pm-11pm EST

Flexibility to work alternating weekends 9am-8pm EST including 2 holidays per year.

Interview Format:

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule.
 
If you are selected, you will receive correspondence inviting you to participate in a Modern Hire assessment.  You will have a set of questions and you will provide responses to each question. You should anticipate this to take about 15 - 20 minutes. Your answers will be reviewed and you will subsequently be informed if you will be moving forward to next round.

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