Pharmacy Claims Specialist

Biloxi, MS 39530

Industry: Healthcare Job Number: LB791365418 Pay Rate: $16 / hour State: MS

Job Description

The ability to utilize a personal computer and applicable department/organizational software
The ability to exercise sound judgment and possess strong problem solving skills
The ability to ask probing questions and obtain thorough and relevant information
The ability to deliver highly technical information to less technical individuals
Knowledge of the most common brand and generic drug names
Knowledge of third party prescription claims adjudication programs and processes
Knowledge of managed care principles and reimbursement policies and procedures
Knowledge of basic medical terminology and understanding of National Drug Code (NDC)
Knowledge of 340B program and regulations governing administration and compliance
Knowledge of Mississippi Board of Pharmacy and Federal controlled substances regulations
Must have effective verbal and written communication skills and demonstrate the ability to
work well within a team
Must demonstrate professional and ethical business practices, adherence to company
standards, and a commitment to personal and professional development
Proven time management skills and the ability to work in a production focused environment are a must
Must demonstrate the ability to manage multiple priorities or tasks, deliver timely and accurate work products with a customer service focus, and respond with urgency as required – Must perform all other duties as assigned
Must have high school diploma or equivalent and 1-2 years of experience in a pharmacy setting
Must be Nationally Certified by Pharmacy Technician Certification Board
Knowledge and experience in Medicare Parts A & billing and in the adjudication of pharmacy claims
Must be able to sit or stand for extended periods of time and to lift items greater than 40 pounds above shoulders
May require frequent bending of knees and back
Must possess a valid driver’s license, reliable transportation, and willingness to travel to different pharmacy locations as required
High school or equivalent (Required)
Under the direct supervision of the Director of Pharmacy Services, the Pharmacy Claims Specialist is responsible for the reconciliation of pharmacy third-party claims, investigating denied, non-matched unpaid and/or underpaid claims, and posting claim reconciliation and receivables within pharmacy data system
Conducts routine administrative and clerical tasks such as answering the phones, filing documents, ordering supplies, stocking shelves, and processing insurance and self-pay payments
Assists in the administration of 340B and other medication-related patient assistance programs
Performs additional duties as required by supervisory personnel
Generating monthly statements, processing and entering payments, and reconciling third-party claims through the pharmacy data system accounts receivable
Assisting the Accounting Department in collecting data for claims audits
Serve as a subject matter expert for complicated processing for prescriptions
Work cross functionally with other departments and shifts with auto-billing and other queues
Claims adjustments and review
Adjudicating insurance claims and troubleshooting rejected claims
Ensure compliance of 340B pharmacy and third-party billing practices
Prescription data entry and filling of medication orders as required
Providing customer service through phones, checking emails and messages to pharmacy and responding promptly and professionally
Communication with insurance parties via inbound and outbound calls
Analyzing pre- and post- adjudication reports for training opportunities and compliance
Performs other duties as requested and/or required
Upholds, complies with, and enforces the Core Principles and Code of Conduct

Meet Your Recruiter

Lindsey Barnes

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