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We have modest goals: Improve the lives of others. Change the landscape of health care forever. Leave the world a better place than we found it. Such aspirations tend to attract a certain type of person. Crazy talented. Compassionate. Driven. To these individuals, we offer the global reach, resources and can-do culture of a Fortune 5 company. We provide an environment where you’re empowered to be your best. We encourage you to take risks and in return, offer a world of rewards and benefits for performance. Exceeding your limits is an exceptional start to your life's best work.SM


Just like you, we are driven by a set of fundamental principles that are guiding our way forward. Our values of integrity, compassion, relationships, innovation, and performance serve as a foundation to transform health care. Are you in? Learn more about your future at UnitedHealth Group at careers.unitedhealthgroup.com


Job Category:

Network Management



Approximate Salary:

Not Specified

Position Type:

Full Time

Contract Reimbursement Specialist - Phoenix, AZ

UHG - Phoenix, Arizona

Posted: 12/7/2018

This is an opportunity that's all about where you've been. Your experience. Your potential. Your skills. All pretty strong up to now. It's also an opportunity about what's ahead. Because on the team at UnitedHealth Group, your potential and your impact can be career changing. We're building and maintaining extensive provider networks to serve our customers. Our goal is to attract and secure relationships with the best in every specialty and every community. As a member of our provider credentialing team, you'll help us vet and document the competencies of physicians and other providers in our networks. As you do, you'll discover the resources, backing and opportunities that you'd expect from a Fortune 6 leader.

This position will be responsible for facilitating daily managed care functions, managing third - party switching services including but not limited to implementing new Avella programs that process through internally set up carrier codes. The main function of this role will be to maintain the relationship between Avella and the switch vendor, monitor Managed Care distribution emails, communicate with other Avella departments such as operations, review plan updates, analyze rejected claims, maintain an ongoing list of third - party contracts that Avella holds and oversee day - to - day activities and acts as the liaison of the Managed Care department.

Primary Responsibilities:

  • Maintain relationship with switch vendor
  • Develop and oversee management of new and current internally created Processor Control Numbers and pre / post edits
  • Monitor, respond and ensure emails submitted to the Managed Care distribution email are addressed timely
  • Assist in monitoring and responding to Managed Care Trouble Tickets
  • Researching low cost claims, claims with reimbursement issues, claims that are requested to be rebilled
  • Assist in admin - rebills when necessary and approved by claim analysis supervisor
  • Successfully resolving reimbursement issues and communicating resolution
  • Maintain third - party contract database
  • Download, save and distribute Managed Care reports
  • Monitor plan, network and payer changes
  • Basic understanding of third - party contracts and payers
  • Maintain a basic knowledge of third - party insurance contracts, how they apply to claim reimbursement and the overall margin of claims within each contract. Third - party contracts and accounts are traditionally made up of managed care payer clients, Pharmacy Benefit Manager contracts, Medical billing, Medicaid FFS and Managed, Medicare DMEPOS and Part D, plan specific, employers, or large physician organizations and currently represent (insert % of revenue Avella obtains via insurance billing my guess is 80 - 90%)in revenue annually
  • Communicate claim issues, reimbursement changes or issues with appropriate account manager
  • Maintain understanding of NCPDP and NPPES
  • Monitor plan updates and changes
  • Analyze, rejected claim report and communicate necessary information on rejected claims by specific plan, network or contract
  • Maintain an understanding of Avella drug mix by pharmacy specifically specialty drugs and limited distribution drugs
  • Ensure and aid in communicating pharmacy issues related to contract are resolved timely and work closely with client to prevent future issues
  • Communicate reports, results, and proposals to internal executive staff
  • Maintain 100% accuracy of switching services including but not limited to internal Processor Control Numbers and pre / post edits

Required Qualifications:

  • Associates Degree (or higher) or equivalent of a minimum of 5 years’ experience in an equivalent full - time pharmacy or customer service related role

  • Licensed Pharmacist or Certified Pharmacy Technician
  • Basic understanding of pharmacy claims processing workflow, pharmacy management system, switching service and Pharmacy Benefit Manager processes
  • Skilled in Microsoft Excel on a basic level (ability to set up spreadsheets, sort and filter data)
  • Demonstrate ability to develop and manage relationships with management, co-workers and all Avella staff specifically related to pharmacy operations
  • Skilled in critical thinking, strong verbal and written communication, including presentation skills that is effective with all levels of management, teams, clients, and vendors
  • Ability to effectively communicate Avella value offering in verbal or written communication or during client presentations
  • Ability to travel up to 25%.

 Preferred Qualifications:

  • Extensive knowledge and understanding of carrier codes and how they function within the pharmacy software system
  • Knowledge of managed care and specialty pharmacy industry and experience with client relationship building, negotiations, and budget management.

Physical Demands and Work Environment

  • The physical demands and work environment are characteristic of those found in a typical business office environment.  Reasonable accommodations may be made for individuals with disabilities to perform essential functions. This position has travel requirements of up to 25%.
When it comes to providing new hope and a new path to wellness, specialty pharmacy companies like Avella fill a unique and important role. Avella, now part of the Optum and UnitedHealth Group family of businesses, is bringing breakthrough medications, innovative clinical pharmacy programs and technological tools to providers and their patients across the nation. We create a viable level of access to many of the newest, most advanced medications in addition to a suite of tools that include mobile apps, text messaging tools and smart pill bottles. Whether you bring a clinical or business background to our opportunities, you can be sure that you'll be making a meaningful contribution to important solutions and services. Find out more about how you can start doing your life's best work.SM

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

Keywords: Contract Reimbursement Specialist, Pharmacist, Certified Pharmacy Technician, Customer Service

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