Under the direct supervision of the Director of Pharmacy Services, the Pharmacy Claims Specialist is responsible for the reconciliation of pharmacy third-party claims, investigating denied, non-matched unpaid and/or underpaid claims, and posting claim reconciliation and receivables within pharmacy data system. Conducts routine administrative and clerical tasks such as answering the phones, filing documents, ordering supplies, stocking shelves, and processing insurance and self-pay payments. Assists in the administration of 340B and other medication-related patient assistance programs. Performs additional duties as required by supervisory personnel.
Knowledge, Skills, and Abilities
The ability to utilize a personal computer and applicable department/organizational software.
The ability to exercise sound judgment and possess strong problem solving skills.
The ability to ask probing questions and obtain thorough and relevant information.
The ability to deliver highly technical information to less technical individuals.
Knowledge of the most common brand and generic drug names.
Knowledge of third party prescription claims adjudication programs and processes.
Knowledge of managed care principles and reimbursement policies and procedures.
Knowledge of basic medical terminology and understanding of National Drug Code (NDC).
Knowledge of 340B program and regulations governing administration and compliance.
Knowledge of Mississippi Board of Pharmacy and Federal controlled substances regulations.
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
Proven time management skills and the ability to work in a production focused environment are a must.
Must demonstrate the ability to manage multiple priorities or tasks, deliver timely and accurate work products with a customer service focus, and respond with urgency as required – Must perform all other duties as assigned.
Must have high school diploma or equivalent and 1-2 years of experience in a pharmacy setting. Graduation from a formal training program is preferred but will accept equivalent work experience in lieu of. Must be Nationally Certified by Pharmacy Technician Certification Board. Knowledge and experience in Medicare Parts A & billing and in the adjudication of pharmacy claims. MAC appeals experience is also desired.
- Generating monthly statements, processing and entering payments, and reconciling third-party claims through the pharmacy data system accounts receivable.
- Assisting the Accounting Department in collecting data for claims audits.
- Serve as a subject matter expert for complicated processing for prescriptions.
- Work cross functionally with other departments and shifts with auto-billing and other queues.
- Claims adjustments and review.
- Understanding of Medicare Part D, commercial insurance, and Medicaid.
- Adjudicating insurance claims and troubleshooting rejected claims.
- Completing prior authorization forms if necessary.
- Ensure compliance of 340B pharmacy and third-party billing practices.
- Prescription data entry and filling of medication orders as required.
- Providing customer service through phones, checking emails and messages to pharmacy and responding promptly and professionally.
- Communication with insurance parties via inbound and outbound calls.
- Analyzing pre- and post- adjudication reports for training opportunities and compliance.
- Must be able to sit or stand for extended periods of time and to lift items greater than 40 pounds above shoulders.
- May require frequent bending of knees and back.
- Must possess a valid driver’s license, reliable transportation, and willingness to travel to different pharmacy locations as required.
- Performs other duties as requested and/or required.
- Upholds, complies with, and enforces the Core Principles and Code of Conduct.
Please submit resumes with position applying for on the subject line to [email protected]