Pharmacy Desktop Auditor Claims Professional 2

Profile

Job Information

Humana

Pharmacy Desktop Auditor (Claims Professional 2)

in

Sandy

Utah

Description

The Humana Pharmacy Solutions traditional Desktop Audit team oversees and manages multiple aspects related to reviewing pharmacy claim submissions for accuracy and appropriateness. Facilitation of discussions with CMS representatives and leaders of other teams is utilized by Desktop Audit team members to continuously improve the audit process in a field of ever evolving standards and regulations. Associates of the Desktop Audit team set the tone and standard for pharmacy claim review. The Pharmacy Claims Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

Primary responsibilities include:

Initiate notifications of multiple types of pharmacy audits including Desktop, CMS and PDE audits.

Review prescription documentation provided by pharmacies, make determination of appropriate claim submissions, document and explain any discrepancies, respond to pharmacy inquiries and perform courtesy calls to pharmacies as needed.

Perform specific audit-related functions within the Audit program which can include calling on suspicious claim submissions, performing state specific law research and quality assurance.

Support the inbound mail and letter process as needed.

Maintain Pharmacy Technician Certification including learning industry changes and completing CE's required to renew certification.

Key Competencies

Builds Trust: You honor your word by doing what you say you are going to do.

Drives for excellence: You are a continuous learner who encourages others to learn. By constantly upgrading your own work, you achieve results and outperform the competition.

Implementation/Execution: You are good at organizing and managing multiple priorities and/or projects by using appropriate methodologies and tools.

Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.

Required Qualifications

Currently Certified Pharmacy Technician (PTCB)

Excellent organizational and time management skills with attention to detail

Prior problem solving experience, including root cause analysis and resolution

Strong written and verbal communication skills

Prior demonstration of process improvement ideologies and implementations

Proficiency in Microsoft Office applications, including Word, Excel and Outlook

Preferred Qualifications

Bachelor's Degree or equivalent combination of education and experience

Prior pharmacy claims experience

Knowledge of Humana Pharmacy claims processing system and processes

Additional Information

Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance for Humana systems is 10Mx1M

Vaccination Info

For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.

If progressed to offer, you will be required to:

Provide proof of full vaccination or commit to testing protocols

*OR  *

Provide proof of applicable exemption including any required supporting documentation

​​Medical, religious, state and remote-only work exemptions are available.

Interview Format

As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called Modern Hire. Modern Hire Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.

If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Alert:

Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from

Humana@myworkday.com

with instructions to add the information into the application at Humana's secure website

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com