The Pharmacy Claims Analyst will work with team members in healthcare payment & reimbursement methodologies, laws and regulations under the mentorship and guidance of the Project Manager.
This position reports to the Director, Project Management Office
Essential Job Functions include the following. Other duties may be assigned.
- Support IT staff in the development and maintenance of pharmacy ETL solutions and NCPDP transactions, which exchange various data streams and constructs with external trading partners (Vendors, providers, and health care regulators, etc.) using a variety of proprietary and standardized interchange methodologies (sFTP, Compression, encryption) and formats (NCPDP, HL7, ANSI X.12, JSOM, XML, CSV/Pipe, Tab, etc.)
- Configure pharmacy claims adjudication business rules, including benefits, cost accumulators, edits and AWP payment methodologies.
- Define, diagram, and document Standard Operating Procedures, Business Requirements, Functional Design Specifications, ERDs, process/workflow models, Data Dictionaries, End-User Documentation, and Unit and Test plans/cases related to retail pharmacy claims adjudication.
- Determine process improvement opportunities and identifying claims processing efficiency opportunities
- Interact with subject matter experts and other dependent stakeholders on a daily basis to perform their job duties
- Maintain confidentiality of data is required
- Interact with external vendor/government entities
- Work with IT leads to support business functional testing for changes/enhancements
- Participate in the design, testing, and deployment of ?software solutions that address the needs of stakeholders, providers, members, and other trading partners, and are consistent with industry, State, Federal (Ex. CMS, HHS, SAMHSA, OIG, etc.) regulatory standards (HIPAA, CMS Interoperability, etc.)
- Analyze the needs of internal and external stakeholders relating to the collection, maintenance, exchange, and delivery of pharmacy healthcare claim that support claims adjudication operations and reimbursement services' initiatives.
- Utilize various technologies (MS Teams, JIRA, Confluence, MS Visio) in an agile and collaborative team-oriented development environment (Scrum and Agile knowledge and experience desirable).
- Participate in business requirements meetings to gather and document business requirements. Help to define functional requirements needed for internally developedsolutions
- Review and audit processed claims
Knowledge & Experience:
- Requires a BA/BS degree
- 3 years related experience (pharmacy claims adjudication operations)
- Any combination of education and experience, which would provide an equivalent background
- Experience in high-volume healthcare operations (claims, benefits, eligibility, testing)
- Pharmacy claims review, processing and testing experience
- NCPDP knowledge
- Awareness of NCPDP reject codes and benefit parameters that drive to the reject codes
- Issue management experience (identifying, reporting issues and tracking them to closure)
- Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
- Data analysis skills
- Experience in performing claims review and determining claim payments for Plan and member responsibility
General Areas of Accountability:
Must conduct business and personal affairs in a manner that is always a credit to the company. Must maintain a good credit rating while employed with the company.
Machines and Equipment:
The incumbent must be able to effectively operate the current computer system, telephone system, and other office machines such as copier and fax machines.
The incumbent must be able to finger, grasp, feel, see, sit, hear, and speak. This position is sedentary in nature with minimal lifting requirements.
The incumbent works in an office environment that is not substantially exposed to adverse environmental conditions such as heat, cold, or extreme noise. Routine periods of being on the phone utilizing a headset, sitting and data keying are required.
Remote Eligibility: This position is eligible for fulltime remote work. Eligibility is determined by Management or Human Resources.
The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.