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.
- 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
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%.
- 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%.
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