Pharmacy/Billing Technician

🕒 Maio 20

🎸 Tennessee – Remoto

🎸 Tennessee – Remote

⏰ Tempo Integral

🟢 Júnior

🟡 Pleno

📊 Especialista em Faturamento

🚫👨‍🎓 Sem graduação necessária

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American Health Partners

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 1976

⚕️ Seguro de Saúde

Healthcare Insurance

American Health Partners é uma organização de saúde focada em melhorar o acesso e a coordenação de cuidados de alta qualidade por meio de um continuum de serviços adaptados a populações institucionais e com necessidades especiais. A empresa opera planos de saúde para necessidades especiais institucionais e fornece coordenação de cuidados especializada, cuidados geriátricos internados e cuidados psiquiátricos agudos, além de serviços de farmácia para unidades de cuidados de longo prazo, apoiados por uma rede de locais próprios/afiliados e milhares de provedores contratados. A American Health Partners enfatiza cuidados preventivos e convenientes para reduzir internações hospitalares dispendiosas e melhorar os resultados dos pacientes e a qualidade de vida.

Descrição

• Review daily point-of-service (POS) pharmacy claims, resolve actionable items, track, and provide reporting • Investigate and resolve pharmacy claim rejections, reversals, and payment discrepancies in real time • Collaborate with external pharmacy and claims teams to ensure accurate claim adjudication and payment • Submit and track claim overrides when appropriate and compliant with plan and CMS guidelines • Facilitate the prior authorization process by working with prescribers, pharmacies, and internal clinical staff • Monitor PA status and proactively communicate determinations and next steps to pharmacies and providers • Serve as primary billing and claims contact for contracted network and long-term care pharmacies • Communicate professionally with pharmacy billing teams, prescribers, and facility staff to resolve claims issues • Educate pharmacies and provider offices on billing requirements, formulary limitations, and plan processes • Support transitions of care by ensuring medication access and clean claim processing for new or discharged members • Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies • Accurately document all claim interventions, communications, and resolutions in the plan’s system • Assist with internal audits, reporting, and quality improvement initiatives related to claims and billing • Identify trends in claim rejections or PA delays and escalate systemic issues to leadership • Monitor daily billing and claims work queues and meet productivity and turnaround time expectations • Participate in cross-functional meetings with pharmacy operations, clinical, and provider relations teams • Support process improvement initiatives to enhance claims efficiency and member access to medications • Serve as a liaison with Enrollment Department to assure appropriate member eligibility processing • Recognize formulary requirements: prior authorization (PA), Step Therapy (ST), Quantity Limit (QL) and understand NCPDP reject codes • Coordinate clinical reporting • Follow-up and solve open items in a timely manner • May be assigned to work on special projects and business initiatives

🎯 Requisitos

• High school diploma or equivalent • Minimum of 2 years as a Pharmacy technician, long term care, or health plan experience • Experience in planning and implementation • Experience working pharmacy claims, rejections, and PA’s • Proficient with Microsoft Suite applications • Strong analytical skills • Proficient communication and presentation skills • Adhere to Centers of Medicare and Medicaid Services (CMS) regulations and compliance requirements • Successful completion of required training

🏖️ Benefícios

• Equal Opportunity Employer