Job summary
The Pharmacy Claims Representative 2 adjudicates pharmacy claims and process pharmacy claims for payment.Performs varied activities and moderately complex administrative/operational/customer support assignments.Typically works on semi-routine assignments.
Job seniority: mid-to-senior level
Responsibilities
• Assist in setting up and maintaining hospice/facility/pharmacy relationships• Assist pharmacies with claims adjudication• Complete incoming tasks assigned by the Pharmacy Claims Team Leaders and the Pharmacy Claims (Support Services) Manager• Obtain necessary information for facilities and their related pharmacies• Assist the Call Center management team with projects to enhance workflow and success• Assist Customer Service team with claims research/resolution• Assist pharmacies with claims adjudication by adjusting/correcting authorizations• Ensure timely adjudication of prescription claims• Contact hospices for authorizations/approvals for submitted claims• Ensure accuracy of patient profile data• Research and correct pharmacy invoices from hospices• Demonstrate basic understanding of Enclara Pharmacia standard/custom formularies• Assist Customer Service team with claims research/resolution• Evaluate compound claims for proper ingredients/qtys/cost• Research claims for hospice/pharmacy audits• Complete assigned facility/pharmacy spreadsheet by contacting facilities and pharmacies• Coordinate all information for facility pharmacies including verification of PBM systems• Update facility pharmacy spreadsheets and implementation team members• Communicate with facility pharmacies on proper billing procedures and contact information• Gather partial information from Call Center on facilities not listed• Obtain correct information to be entered into the database• Link facilities to their respective hospices• Assist with Confirmation Fax reports to update facility and pharmacy relationships and demographic information
Requirements
• Strong verbal and written communication skills• 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• 1+ years of Pharmacy Technician experience• Strong knowledge working with pharmacy claims adjudication• Must have experience with electronic claims submissions OR be a current internal Enclara Pharmacia associate• PBM experience is preferred• Dispensing system experience is preferred• CPhT or EXCPT is preferred• High school diploma is preferred
Benefits
• Competitive benefits that support whole-person well-being• Medical, dental, and vision benefits• 401(k) retirement savings plan• Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)• Short-term and long-term disability• Life insurance
