Pharmacy Claims Professional 2

Humana Boston, KY 2019-07-10

Description

The Pharmacy Claims Professional 2 analyzes and answers inquiries regarding pharmacy claims adjudication, including method of payment, co-pay or deductible amounts, and/or reason for denial. Works closely with a senior professional and understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Responsibilities

The Pharmacy Claims Professional 2 w ill work with pharmacies who have balances on previously paid claims. This is a highly impactful role in terms of financial recovery and pharmacy experience. You will make decisions on moderately complex to complex issues regarding technical approach for project components, and gain a broad base of claims knowledge. Enjoy a schedule that includes 4-days of Work-At-Home, and one day in the office per week, for meetings, etc. You will be able to exercise considerable latitude in determining objectives and approaches to assignments. Responsibilities include:

  • Make direct phone calls and/or send letters to pharmacies in Humana’s network to perform financial recoveries related to overpayments and audit adjustments.
  • Provide required support on a claim level to the pharmacies with outstanding balances.
  • Collaborate with Pharmacy Audit when needed to gain a sufficient understanding of causes for the balances.
  • Maintain written correspondence related to recoveries. Utilize existing, approved letters and make changes as required.
  • Update various reports on a timely basis.
  • Other duties as assigned.

<<< The office is located in Louisville, KY, and you will need to work in-office one day per week. >>>

Required Qualifications

  • Bachelor's degree
  • 5+ years of data analysis & problem solving regarding process and work flow concepts
  • Demonstrated proficiency in MS Office applications including Access, Excel, and Visio
  • Strong consultative skills and relationship building skills
  • Strong verbal and written communication skills
  • Strong organizational and time management skills
  • Ability to handle multiple tasks, meet deadlines, and follow-up timely
  • Ability to work in a fast paced, dynamic and changing environment while managing multiple projects simultaneously
  • Strong attention to detail

Preferred Qualifications

  • Previous experience with pharmacy benefits management
  • Claims experience
  • Knowledge/experience working with SQL (via MS SQL Server, Oracle, PL/SQL or other)

Additional Information

Scheduled Weekly Hours

40
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