Benefits Processor


  • Job ID:

    2061
  • Pay rate range:

    $14 - $18
  • City:

    Brockton
  • State:

    Massachusetts
  • Duration:

    10/21/2019 - 10/21/2020
  • Job Type:

    Contract
  • Job Description

    3rd Party Claims Specialist

    Ensure maximum reimbursement by resolving payer rejected claims with critical deadlines while adhering to compliance standards and mitigating financial risk to our customers in a high volume, fast paced environment.

    • Manage and identify a portfolio of rejected pharmacy claims to ensure maximum payer reimbursement and timely billing to eliminate financial risks to Corporate and their customers.
    • Research, analyze and appropriately resolve rejected claims by working with national Medicare D plans, third party insurance companies and all state Medicaid plans to ensure maximum payer reimbursement adhering to critical deadlines.
    • Ensure approval of claims by performing appropriate edits and/or reversals to ensure maximum payer reimbursement.
    • Contact providers and/or customers as necessary to obtain additional information.
    • Monitor and resolve at risk revenue associated with payer set up, billing, rebilling and reversal processes.
    • Work as a team to identify, document, communicate and resolve payer/billing trends and issues
    • Timely complete, communicate and submit necessary payer paperwork including but not limited to prior authorizations forms and manual billing.
    • Review and work convert billing exception reports to ensure claims are billed to accurate financial plans.
    • Complete billing transactions for non standard order entry situations as required.
    • Support training needs
    • Prepares and maintains reports and records for processing.
    • Performs other tasks as assigned.
    • Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.

    • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required.  Each essential function is required, although reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    • Education/Learning Experience

    • Required:  High School Diploma or GED
    • Desired:  Associate’s or Bachelor’s Degree

     

    • Work Experience

    • Required: Customer Service

    • Desired:  Up to one year of related experience.  Pharmacy Technician experience. 

     

    • Skills/Knowledge

    • Required:  Ability to retain a large amount of information and apply that knowledge to related situations.  Ability to work in a fast paced environment.  Basic math aptitude.   Microsoft Office Suite

    • Desired:   Knowledge of the insurance industry’s trends, directions, major issues, regulatory considerations and trendsetters. 

    • Licenses/Certifications 

    • Required: 

    • Desired:   Pharmacy technician

    • Behavior Competencies

    • Required:  Customer Service.  Oral and written communication.   Detail Orientation.  Results Orientation.  Teamwork. Adaptability to an ever changing environment.

    Desired: Analytical and problem solving

    • Standing

     

    • Sitting

     

    • Walking

     

    • Lifting

     

    The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    #PCO, #PHARMA

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