Pharmacy Claims Professional 2 - Overpayment Team

Profile

Description

The Pharmacy Claim Professional 2 conducts reviews on pharmacy claims to assess for recoveries. The Pharmacy Claim Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Pharmacy Claims Professional 2 analyzes and answers inquiries regarding pharmacy claims adjudication, including method of payment, co-pay or deductible amounts, and/or reason for denial. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Potential candidate could be assigned one or more work streams which may consist of the following: Invalid Prescriber ID, Invalid NDC, ESRD B vs D, Transplant B vs D, Hospice A vs D, LTI A vs D, Deceased Member, Expired Scripts, Insulin B vs D, Wrong Member Billed, Medicare Secondary Payer, Commercial vs Part B, and Retro Term

Will be supporting Pharmacy Claim Audit and Review Overpayment team members in various capacity

Will be utilizing the following systems and applications: PCAR Auditing system, Access, SQL, Excel, MARx, Word and PowerPoint

Builds relationships and collaborates with other PCAR areas

Summary of findings and articulation and presentation and recommendation to leadership

Engages in process to initiate recoveries including: claims analysis, letters, and tracking of recoveries for assigned work stream; responding and answering phone calls, etc

As needed; potential candidate will identify broader retrospective review of current work steam or identification of new work streams

Required Qualifications

Bachelor's degree or equivalent experience

Minimum of 1 year proven experience of data analysis & problem solving skills

Comprehensive/working knowledge of all Microsoft Office applications, including Access, Word, Excel and PowerPoint. Including database creation and maintenance.

Previous experience with Medicare Part A, B, C and D

Knowledge/experience working with SQL (via MS SQL Server, Oracle, PL/SQL or other). Including query creation.

Excellent Time Management

Preferred Qualifications

Point of Sale Claims processing knowledge

Pharmacy Tech experience

Previous experience with pharmacy benefits management

Previous vendor management experience

Previous customer service experience

Ability to handle multiple tasks, meet deadlines, and follow-up timely

Strong organizational and time management skills

Strong verbal and written communication skills, including the ability to tailor communication to audience

Medical claims experience

Previous vendor management experience

Process Improvement experience

Additional Information

Scheduled Weekly Hours

40

Company info

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