Pharmacy Claims Representative

DescriptionThe Pharmacy Claims Representative 2 adjudicates pharmacy claims and process pharmacy claims for payment. The Pharmacy Claims Representative 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.ResponsibilitiesThis is a work at home opportunity.Schedule : We have three positions and shifts availableSchedule 1: Monday through Friday 10:15am - 6:45pm with every 4th weekend rotations (Sun and Saturday)Schedule 2: Monday through Friday 11:15am - 7:45pm with every 4th weekend rotations (Sun and Saturday)Schedule 3: Monday through Friday 12pm - 8:30pm with every 4th weekend rotations (Sun and Saturday)Enclara, is a wholly owned hospice and palliative care pharmacy business acquired by Humana in 2021. Enclara is the nation's largest full-service pharmacy benefits manager (PBM) specifically for the hospice and palliative care sectors. Serving over 450 customers and nearly 100,000 patients nationally, Enclara works closely with hospices to reduce pharmacy costs, improve patient care and support caregivers through: digital innovations, flexible medication access, one-on-one clinical support, and excellent customer service.SummaryAssist local pharmacies with claims adjudication to support medication access for HC & LTC hospice patients; reconcile historic billing issues.Essential Duties and Responsibilities:Assist in setting up and maintaining hospice/facility/pharmacy relationships under the direction of the Pharmacy Claims Team Leaders & the Pharmacy Claims (Support Services) Manager

Assist pharmacies with claims adjudication

Complete incoming tasks as assigned by the Pharmacy Claims Team Leaders and the Pharmacy Claims (Support Services) Manager

Obtain all necessary information for facilities and their related pharmacies

Assist the Call Center management team with projects to enhance the workflow and success of the Call Center

Assist Customer Service team with claims research/resolution

RESPONSIBILITIES (include but are not limited to):Billing:Assist pharmacies with claims adjudication by adjusting/correcting authorizations in dispensing systems and PBM systems

Ensure timely adjudication of prescription claims through PBM systems

Contact hospices for authorizations/approvals for submitted claims where necessary

Ensure accuracy of patient profile data including related/not related status, authorization status, etc

Research and correct pharmacy invoices from hospices

Demonstrate basic understanding of Enclara Pharmacia standard/custom formularies

Understand formulary and billing platform differences (PD vs. FFS) from hospice to hospice

Assist Customer Service team with claims research/resolution via dispensing systems, PBM systems and fax systems

Evaluate compound claims for proper ingredients/qtys/cost and ensure timely claims adjudication

Research claims for hospice/pharmacy audits

New Hospice Start-Ups:Complete assigned facility/pharmacy spreadsheet by contacting both the facilities and pharmacies to verify accuracy of all information provided

Coordinate all information for facility pharmacies including verification of PBM systems

Update facility pharmacy spreadsheets and implementation team members on the progress with these pharmacies

Communicate with the facility pharmacies on proper billing procedures and contact information for rejected claims

New Facilities:Gather partial information from Call Center on facilities not listed and obtain correct information to be entered into the database

Link facilities to their respective hospices once all information is obtained.

Assist with Confirmation Fax reports to update facility and pharmacy relationships and demographic information

Qualifications:Strong verbal and written communication skills, including the ability to tailor communication to audience

Self-motivated, organized

Team player

Problem-solving skills and ability to follow through on tasks assigned

Ability to handle multiple tasks, meet deadlines, and follow-up timely

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

Required Education and/or Experience:At least 1 year of Pharmacy Technician experience

Knowledge of pharmacy claims and adjudications

High school diploma

Preferred Experience:PBM experience

Dispensing system experience

CPhT or EXCPT

Covid Vaccination PolicyWe will require full COVID vaccination for this job as 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 documentation for a medical or religious exemption consideration where allowed by law.

Scheduled Weekly Hours40