About Humana


Job Category:

Consumer Service Operations - Claims


United States

Approximate Salary:

Not Specified

Position Type:

Full Time

Senior Pharmacy Claims Professional

Humana - Work At Home, Kentucky

Posted: 12/14/2018


The Senior Pharmacy Claims Professional adjudicates pharmacy claims and process pharmacy claims for payment. The Senior Pharmacy Claims Professional work assignments involve moderately complex to complex issues of financial recovery where the analysis of situations or data requires an in-depth evaluation of variable factors.


The Senior Pharmacy Claims Professional will work with pharmacies who have balances on previously paid claims. This is a highly impactful role in terms of financial recovery and pharmacy experience. You will make decisions on moderately complex to complex issues regarding technical approach for project components, and gain a broad base of claims knowledge. Enjoy a schedule that includes 4-days of Work-At-Home, and one day in the office per week, for meetings, etc. You will be able to exercise considerable latitude in determining objectives and approaches to assignments. Responsibilities include:

  • Provide support on a claim level for the pharmacies with outstanding balances.  Collaborate with Pharmacy Audit when needed to gain a sufficient understanding of causes for the balances.
  • Update various reports on a timely basis.
  • Maintain written correspondence related to recoveries.  Utilize existing, approved letters and make changes as required.
  • Make direct phone calls to pharmacies in Humana’s network to perform financial recoveries related to overpayments and audit adjustments.
  • Lead conference calls with internal areas during discussions related to upcoming claim adjustments, pharmacy terminations, fraud and abuse cases, etc.
  • Maintain relationship and exchange of information and reports with external collection agency partner.
  • Participate in conversations with Humana legal department in cases of unsuccessful attempts to collect through available means.
  • Other duties as assigned.
  • The office is located in Louisville, KY, and you will need to work in-office one day per week.


Required Qualifications

  • Bachelor's degree
  • 5 years of data analysis & problem solving regarding process and work flow concepts
  • Demonstrated proficiency in MS Office applications including Access, Excel, and Visio
  • Strong consultative skills and relationship building skills
  • Strong verbal and written communication skills
  • Strong organizational and time management skills
  • Ability to handle multiple tasks, meet deadlines, and follow-up timely
  • Ability to work in a fast paced, dynamic and changing environment while managing multiple projects simultaneously
  • Strong attention to detail

Preferred Qualifications

  • Previous experience with pharmacy benefits management
  • Claims experience
  • Proven experience with process improvement

Scheduled Weekly Hours


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