Claims Analyst – 3rd Party

Claims Analyst – 3rd Party

Requirements

• Experience in Customer Service
• 2+ yrs experience as a Pharmacy Technician or in a billing position within a healthcare setting
• 1+ yrs experience with pharmacy or health data analysis
• 1+ yrs experience working in a Pharmacy, Long Term Care or Managed Care setting
• Ability to work in the Eastern Time Zone
• HS Diploma, GED or equivalent experience is required
• Excellent verbal and written communication skills needed
• Excellent time management skills; ability to work independently and manage multiple/competing priorities required
• Proven ability to work with a high degree of accuracy and attention to detail
• Proficient in all Microsoft Word and Outlook
• Demonstrated analytical skills, technical knowledge and creative problem solving techniques
• Ability to effectively navigate ambiguous situations with limited direction
• Advanced analytical skills with the ability to interpret and synthesize complex data sets
• Able to handle high volume and significant workload

Responsibilities

• Communicate effectively and professionally with 3rd party entities including Pharmacy Benefit Managers (PBM’s), pharmacy claim switches, and other vendors regarding claim or plan inquiries.
• Understand various payer requirements and configure billing parameters within proprietary software to send online transactions to and from 3rd party insurance payers in accordance with HIPAA named standards set forth by the National Council for Prescription Drug Programs (NCPDP)
• Review 3rd party payer sheets for specific configuration details. Construct telecom standard field specific templates for each payer
• Communicate with Switching company to construct external pre and post claim edits to prevent claim denials and ensure proper reimbursement.
• Send and receive contracts on behalf of the Director of 3rd Party Network Services. Work with Compliance team to obtain, reissue, or renew Medicaid provider ID’s, and work with other internal teams across the organization.
• Serve as Subject Matter Expert (SME) on cross functional work groups
• Provide operational support and troubleshooting to resolve both internal and external inquiries.
• Research and resolve complex billing issues with available resources and tools. This includes researching both denied and paid claim transactions, understanding root cause for denied claims or under reimbursement on paid claims, implementing methods to reduce such claims, or educating pharmacies on prevention opportunities.
• Ensure all industry and/or payer related changes are communicated throughout the organization
• Independently and accurately manage workload in a timely manner with minimal direction. Communicate when competing priorities cannot be managed independently.
• Prepare recurring reports related to claim denials or payments.
• Query, massage, and analyze small to medium sums of claim data. Summarize and report findings to executive management or other internal teams
• Support project teams in the development of functional requirements
• 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.

Preferred Qualifications

• Desired: Associate or Bachelor’s degree
• Query building experience through use of Microsoft Access or other proprietary systems is a preference
• Familiarity with long term care pharmacy or facility billing practices is a preference
• Pharmacy Technician experience and/or knowledge of pharmaceuticals is a strong preference