Pharmacy Claims Representative

Employment Type: Full-time

Location Type: Remote US

Shift: Monday-Friday 2:30 PM - 11:00 PM EST. Flexibility to work alternating weekends between 9:00 AM - 8:00 PM EST. Flexibility to work 2 holidays per year.

Position Overview

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.

Responsibilities

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, and authorization status.
• 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.

General:

• 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.
• 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.

Qualifications

• Strong verbal and written communication skills, including the ability to tailor communication to audience.
• Self-motivated and 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 adjudication.
• Must have experience with electronic claims submissions OR be a current internal Enclara Pharmacia associate.

Preferred Experience:

• PBM experience.
• Dispensing system experience.
• CPhT or PTCB certification.
• Drug knowledge.
• High school diploma.

Travel

While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Salary

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting.