DescriptionThe Pharmacy Claims Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Scope of Role and Responsibilities:
As a Pharmacy Claims Professional 2 you will perform audit functions including review of pharmacy submitted documentation, responding to pharmacy inquiries and supporting other audit functions as needed.
Primary responsibilities include:
• Initiate notifications of multiple types of pharmacy audits including Desktop, CMS and PDE audits.
• Review prescription documentation provided by pharmacies, make determination of appropriate claim submissions, document and explain any discrepancies, respond to pharmacy inquiries and perform courtesy calls to pharmacies as needed.
• Perform specific audit-related functions within the Audit program which can include calling on suspicious claim submissions, performing state specific law research and quality assurance.
• Support the inbound mail and letter process as needed.
• Maintain Pharmacy Technician Certification including learning industry changes and completing CE’s required to renew certification.
• Builds Trust: You honor your word by doing what you say you are going to do.
• Drives for excellence: You are a continuous learner who encourages others to learn. By constantly upgrading your own work, you achieve results and outperform the competition.
• Implementation/Execution: You are good at organizing and managing multiple priorities and/or projects by using appropriate methodologies and tools.
• Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.
• Prior problem solving experience, including root cause analysis and resolution
• Excellent organizational and time management skills with attention to detail
• Strong written and verbal communication skills
• Proficiency in Microsoft Office applications, including Word and Excel
• Currently Certified Pharmacy Technician (PTCB)
• Prior pharmacy claims experience
• Knowledge of Humana Pharmacy claims processing system and processes
• Bachelor’s Degree or equivalent combination of education and experience
Scheduled Weekly Hours40