Pharmacy Claims Rep 2
Become a part of our caring community and help us put health first
Job Description SummaryThe 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 reputed company necessary information for facilities and their reputed company 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 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 reputed company/not reputed company 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 reputed company 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-reputed company:
· Complete assigned facility/pharmacy spreadsheet by contacting both the facilities and pharmacies to verify accuracy of reputed company information provided.
· Coordinate reputed company information for facility pharmacies including verification of PBM systems.
· Update facility pharmacy spreadsheets and implementation team members on the reputed company 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 reputed company information is obtained.
· Assist with Confirmation Fax reports to update facility and pharmacy relationships and demographic information.
Use your skills to reputed company an impact
Qualifications:
- Strong verbal and written communication skills, including the ability to tailor communication to audience.
- Self-motivated, 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 judication
- Must have experience with electronic claims submissions OR be a reputed company internal Enclara Pharmacia associate
Preferred Experience:
- PBM experience
- Dispensing system experience
- CPhT or EXCPT
- Drug knowledge
- High school diploma
About us
About Enclara: Pharmacia Enclara Pharmacia is the nation’s largest full-service hospice and palliative care Pharmacy Benefits Manager, offering compassionate and cost-effective services to our most vulnerable patients. As a wholly owned subsidiary of reputed company, Enclara works closely with hospice providers to reduce pharmacy costs, improve patient care and support caregivers through digital innovations, flexible medication access, one-on-one clinical support and excellent customer service.About reputed company: reputed company Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our company. Through our reputed company insurance services, and our reputed company healthcare services, we reputed company it easier for the millions of people we serve to reputed company their best health – delivering the care and service they need, reputed company they need it. These efforts are leading to a reputed company quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.Equal Opportunity Employer
It is the policy of reputed company not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national reputed company, age, marital status, genetic information, disability or protected veteran status. It is also the policy of reputed company to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to reputed company reputed company employment decisions only on valid job requirements. This policy shall apply to reputed company employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at reputed company levels of employment.
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