Assist local pharmacies with claims adjudication to support medication access for HC & LTC hospice patients; reconcile historic billing issues.
Job Description Summary
The Pharmacy Claims Representative 2 adjudicates pharmacy claims and process pharmacy claims for payment. The Pharmacy Claims Representative 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.
Location: Remote Nationwide
Shift: Monday through Friday 2:30pm – 11pm ET with every 4th weekend rotations (flexible hours on the weekends).
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 all necessary information for facilities and their related 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
Use your skills to make an impact
RESPONSIBILITIES (include but are not limited to):
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 related/not related status, authorization status, etc
• 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 via 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-Ups:
• Complete assigned facility/pharmacy spreadsheet by contacting both the facilities and pharmacies to verify accuracy of all information provided
• Coordinate all information for facility pharmacies including verification of PBM systems
• Update facility pharmacy spreadsheets and implementation team members on the progress 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 all information is obtained.
• Assist with Confirmation Fax reports to update facility and pharmacy relationships and demographic information
Qualifications:
• Strong verbal and written communication skills, including the ability to tailor communication to audience
• Self-motivated, organized
• Team player
• Problem-solving skills and ability to follow through on tasks assigned
• Ability to handle multiple tasks, meet deadlines, and follow-up timely
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
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 current internal Enclara Pharmacia associate
Preferred Qualifications:
• CPhT or EXCPT
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$37,200 – $51,200 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities.
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 Humana, 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 Humana: Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our company. Through our Humana insurance services, and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.