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Job Description:

One of the World's Largest and Fastest growing Pharmaceutical Company with $2 Billion in annual revenue is seeking a 3rd Party Claims Specialist I

Summary

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.

Essential Functions:

Manage and identify a portfolio of rejected pharmacy claims to ensure maximum payer reimbursement and timely billing to eliminate financial risks to our company 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.

Position Qualifications

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

Physical Requirements/Demands of the position

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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