Pharmacy Claims Lead

Profile

Description

The Pharmacy Claims Lead operationalizes and monitors Coordination of Benefits (COB) and subrogation claim processing logic and processes. Exercises independent judgment and decision making on managing staff, complex issues regarding job duties and related tasks, and works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action.

Responsibilities

Responsibilities

Lead a team of Pharmacy Professionals responsible for production oversight and testing of COB and subrogation pharmacy claim functions in the SS&C Pharmacy Solution Point-of-Sale (POS) system

Empower Associates and elevate their voices

Associate engagement and Cultural Competency

Enable personal & professional growth

Develop analytics and reporting needed to support the day-to-day business

Actively identifies and owns process improvements and operates with a high level of personal accountability

Productivity reporting to aid in ensuring that the organizational goals are met

Manage activities related to implementation, monitoring and support of Commercial, Medicare and Medicaid business

Ensure compliance, Federal & State, and engage in external/internal audits

Quality reporting to ensure legislative and process adherence

Develop and document processes. Write and maintain policies and procedures; while ensuring policies and procedures address compliance and regulatory requirements

Effectively collaborate with other Humana departments and Pharmacy Claim Operations teams

Reporting, metrics and trend for pharmacy POS activities

Has expertise in systems and technologies to lead team to increase performance and capabilities while understanding impacts

Additional projects assigned, based on business needs

Required Qualifications

3-5 years of Medical/Pharmacy Claims experience

Prior demonstrated experience with leading end to end process improvement or process design and implementation roles

Working knowledge of all Microsoft Office applications (Word, Visio, Excel and Access) and SQL

Strong consultative skills and relationship building skills

Excellent written and verbal communication skills

Excellent planning and organizational skills

Ability to work on multiple projects

Ability to successfully handle change in a fast paced environment

Preferred Qualifications

Demonstrated strong leadership skills (as defined by informal or formal leadership experience)

Bachelor's Degree or equivalent experience in the health insurance industry

Project Management experience

Scheduled Weekly Hours

40

Company info

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