Senior Pharmacy Claims Professional- Overpayment

Profile

Description

The Senior Pharmacy Claims Professional in the Pharmacy Claim Audit & Review department adjudicates pharmacy claims and process pharmacy claims for payment. The Senior Pharmacy Claims Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Pharmacy Claims Professional in the Pharmacy Claim Audit & Review department analyzes and answers inquiries regarding pharmacy claims adjudication, including method of payment, co-pay or deductible amounts, and/or reason for denial. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Job Duties to include the following:

Support overpayment initiatives, including, but not limited to:

Transplant B vs D

Deceased member

Expired Scripts

LTI A vs. D

Hospice A vs. D

ESRD B vs. D

Insulin B vs. D

Request and monitor claims reports to identify new overpayment initiatives to support day to day business

Ensure compliance by completing and processing overpayments pursuant to state and federal requirements

Develop and document processes

Effectively collaborate with other Humana departments and Pharmacy Claim Audit and Review teams

Support implementation of new auditing system

Ensure system includes all aspects of new work streams

Engage in process to initiate recoveries including: claims analysis, tracking recovers for assigned work streams, responding to phone calls and emails, creating and sending letters

Articulate and present summary of findings and recommendations to leadership

Additional projects as business needs require

Required Qualifications

3-5 years of data analysis & problem solving regarding process and work flow concepts

Pharmacy or Medical claims experience

Demonstrated proficiency in MS Office applications including Word, Excel, and PowerPoint

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

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Previous experience with Medicare Part A, B, C and D

Preferred Qualifications

Previous experience with pharmacy benefits management

Pharmacy Audit experience

Proven experience with process engineering

Pharmacy Technician certification

Point of Sale Claims processing knowledge

Additional Information

Scheduled Weekly Hours

40

Company info

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