Senior Pharmacy Claims Professional

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Job Information

Humana

Senior Pharmacy Claims Professional

in

Green Bay

Wisconsin

Description

The Senior Pharmacy Claims Professional adjudicates pharmacy claims and processes 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 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.

Additional Job Description and Responsibilities

Specific responsibilities for the Senior Pharmacy Claims Professional on the Benefits and Eligibility team will include supporting leaders of the department in progressing department, PBM Operations, and HPS strategic goals.

The Senior Pharmacy Claims Professional will also develop as a Subject Matter Expert (SME) for a variety of knowledge base and processes in the department as assigned by Department leadership.

Finally, the Senior Pharmacy Claims Professional will also conduct and support daily business tasks on the Benefits and Eligibility team.

Responsibilities will include but will not be limited to

Medicare and Commercial Accumulator SME

HCSIM

-Global issues research

-Impact Analysis

-Root cause analysis

VSR Requirements (Developing requirements, validating test cases, testing projects)

Targeted and Regression testing

Review and Analysis of various Accumulator reports

Closer to strategy and direction for Accumulator responsibilities.  Create and determine work.

Medicare and Commercial Audit SME

Research, analyze and provide responses for audits

-Global claims research

-Issue resolution

-Impact Analysis

-Develop written and/or verbal responses for audit requests

Verify compliance with Federal and State regulations

Closer to strategy and direction for Audit responsibilities. 

Create and determine work.

Medicare and Commercial Guideline Monitoring

1.

Coordination of annual guideline review

Maintenance of guideline repository

Routine Audits/Monitoring of Benefits and Eligibility work

Review of testing templates

Review of benefit builds

Responsibilities as assigned.

Required Qualifications

Bachelor's Degree or equivalent pharmacy related work experience

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

Demonstrated proficiency in MS Office applications including Access, Excel, Project 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

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

Preferred Qualifications

Previous experience with pharmacy benefits management

Claims experience

Proven experience with process engineering

Demonstrated proficiency in SharePoint, Power BI, Power Automate

Additional Information

Scheduled Weekly Hours

40

Company info

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