Become a part of our caring community and help us put health first
 

The Pharmacy Claims Representative assists local pharmacies with claims adjudication to support medication access for HC & LTC hospice patients and reconcile historic billing issues.

Location: Remote US

Shift: Monday-Friday 2:30pm-11pm EST. Flexibility to work alternating weekends between the hours of 9am-8pm EST. Flexibility to work 2 holidays per year.

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

*Assist with new hires training

 

Billing:

·       Assist pharmacies with claims adjudication by adjusting/correcting autho rizations 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.

 

Use your skills to make an impact
 

Qualifications:

• Strong verbal