Senior Pharmacy Claims Professional

Profile

Description

The Senior Pharmacy Claims Professional oversees processes and ensures accuracy for pharmacy point of sale coordination of benefits (COB) adjudicated claims. 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, monitors and enhances processes and claims adjudication logic as it pertains to pharmacy COB point of sale claims. Works closely on cross collaborative project teams, with internal and external partners, to identify impact, ensure appropriate project requirements and test projects end to end. Ensures processes are documented, reviewed for appropriateness and compliance and monitored regularly. Begin to influence department's strategy. Makes decisions on moderately complex to complex issues, regarding technical approach for project components and gain a broad base of claims knowledge. Exercises considerable latitude in determining objectives and approaches to assignments. You will have the opportunity to use your expertise in data analysis and problem solving to ensure compliance with state and federal regulations. Responsibilities include:

Subject matter expert for pharmacy COB processes and claims processing logic

Main speaker during CMS Program audits and compliance mock audits

Ensure compliance with all Federal and state requirements

Create, update and maintain various reports and policy/procedure documents

Lead projects with internal/external areas related to required process or logic changes

Other duties as assigned

Required Qualifications

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

Aptitude in Microsoft Office applications, including Access, Word, Excel and PowerPoint

Demonstrated proficiency working with SQL (via MS SQL Server, PL/SQL)

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

Pharmacy or Medical claims experience

Preferred Qualifications

Bachelor's degree

Pharmacy point of sale logic experience

Project testing including building scenarios

Proven experience with process engineering

CMS Chapter 14 knowledge

Additional Information

Must be willing to work in EST

Scheduled Weekly Hours

40

Company info

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