Pharmacy/Billing Technician

🔥 0 minutes ago

🎸 Tennessee – Remote

🎸 Tennessee – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

📊 Billing Specialist

🚫👨‍🎓 No degree required

👻 Ghost score 10%

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American Health Partners

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1976

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

American Health Partners is a healthcare organization focused on improving access to and coordination of high-quality care through a continuum of services tailored to institutional and special-needs populations. The company operates institutional special needs health plans and provides specialized care coordination, geriatric inpatient and acute psychiatric care, and pharmacy services for long-term-care facilities, supported by an owned/affiliated network of locations and thousands of contracted providers. American Health Partners emphasizes convenient, preventive care to reduce costly hospital stays and improve patient outcomes and quality of life.

📋 Description

• Review daily point-of-service pharmacy claims, resolve actionable items, track activity, 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 in compliance with plan and CMS guidelines • Ensure proper coordination of benefits, hospice billing considerations, and Part A/B versus Part D determinations • Facilitate prior authorization processes with prescribers, pharmacies, and internal clinical staff • Gather and submit documentation for prior authorization review; monitor status and communicate determinations • Serve as primary billing and claims contact for contracted network and long-term care pharmacies • 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 • Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies • Document claim interventions, communications, and resolutions in the plan’s system • Assist with internal audits, reporting, and quality improvement initiatives • Identify claim rejection and prior authorization delay trends 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 that enhance claims efficiency and member medication access • Liaise with the Enrollment Department regarding member eligibility processing • Recognize formulary requirements including prior authorization, Step Therapy, Quantity Limits, and NCPDP reject codes • Coordinate clinical reporting • Follow up on and resolve open items in a timely manner • Participate in special projects and business initiatives • Perform other duties as assigned

🎯 Requirements

• High school diploma or equivalent • Minimum of 2 years as a Pharmacy Technician, in long-term care, or health plan experience • Experience working pharmacy claims, rejections, and prior authorizations (PAs) • Experience in planning and implementation • Proficiency with Microsoft Suite applications • Ability to navigate multiple systems • Strong analytical skills • Proficient communication and presentation skills • Adherence to Centers for Medicare and Medicaid Services (CMS) regulations and compliance requirements • Successful completion of required training • Pharmacy Technician certification preferred

🏖️ Benefits

• Reasonable accommodation for applicants with disabilities • Full-time remote work arrangement