• Job Description

  Req#: R-322690

  Description

  The Pharmacy Claims Representative 2 adjudicates pharmacy claims and process pharmacy claims for payment. The Pharmacy Claims Representative 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.

  Responsibilities

  This is a work at home position.

  Assist local pharmacies with claims adjudication to support medication access for HC & LTC hospice patients; reconcile historic billing issues.

  Essential Duties and Responsibilities:

  • Assist in setting up and maintaining hospice/facility/pharmacy relationships under the direction of the Pharmacy Claims Team Leaders & the Pharmacy Claims (Support Services) Manager
  • Assist pharmacies with claims adjudication
  • Complete incoming tasks as assigned by the Pharmacy Claims Team Leaders and the Pharmacy Claims (Support Services) Manager
  • Obtain all necessary information for facilities and their related pharmacies
  • Assist the Call Center management team with projects to enhance the workflow and success of the Call Center
  • Assist Customer Service team with claims research/resolution

  RESPONSIBILITIES (include but are not limited to):

  Billing:

  • Assist pharmacies with claims adjudication by adjusting/correcting authorizations in dispensing systems and PBM systems
  • Ensure timely adjudication of prescription claims through PBM systems
  • Contact hospices for authorizations/approvals for submitted claims where necessary
  • Ensure accuracy of patient profile data including related/not related status, authorization status, etc
  • Research and correct pharmacy invoices from hospices
  • Demonstrate basic understanding of Enclara Pharmacia standard/custom formularies
  • Understand formulary and billing platform differences (PD vs. FFS) from hospice to hospice
  • Assist Customer Service team with claims research/resolution via dispensing systems, PBM systems and fax systems
  • Evaluate compound claims for proper ingredients/qtys/cost and ensure timely claims adjudication
  • Research claims for hospice/pharmacy audits

  New Hospice Start-Ups:

  • Complete assigned facility/pharmacy spreadsheet by contacting both the facilities and pharmacies to verify accuracy of all information provided.
  • Coordinate all information for facility pharmacies including verification of PBM systems.
  • Update facility pharmacy spreadsheets and implementation team members on the progress with these pharmacies.
  • Communicate with the facility pharmacies on proper billing procedures and contact information for rejected claims.

  New Facilities:

  • Gather partial information from Call Center on facilities not listed and obtain correct information to be entered into the database.
  • Link facilities to their respective hospices once all information is obtained.
  • Assist with Confirmation Fax reports to update facility and pharmacy relationships and demographic information.

  Qualifications:

  • Strong verbal and written communication skills, including the ability to tailor communication to audience.
  • Self-motivated, organized
  • Strong attention to detail
  • Team player
  • Problem-solving skills and ability to follow through on tasks assigned
  • Ability to handle multiple tasks, meet deadlines, and follow-up timely.

  Required Education and/or Experience:

  • 1+ years of Pharmacy Technician experience
  • Strong knowledge working with pharmacy claims judication

  Preferred Experience:

  • PBM experience
  • Dispensing system experience
  • CPhT or EXCPT
  • Drug knowledge
  • High school diploma

  Schedule:

  Monday-Friday 2:30pm-11pm EST

  Flexibility to work alternating weekends 9am-8pm EST including 2 holidays per year.

  Interview Format:

  As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule.
  
  If you are selected , you will receive correspondence inviting you to participate in a Modern Hire assessment. You will have a set of questions and you will provide responses to each question. You should anticipate this to take about 15 - 20 minutes. Your answers will be reviewed and you will subsequently be informed if you will be moving forward to next round.

  Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana’s secure website.

  This position is for Enclara Pharmacia , a Humana company. Enclara, is a wholly owned hospice and palliative care pharmacy business acquired by Humana in 2021. Enclara is the nation’s largest full-service pharmacy benefits manager (PBM) specifically for the hospice and palliative care sectors. Serving nearly 140,000 patients nationally, Enclara works closely with hospices to reduce pharmacy costs, improve patient care and support caregivers through: digital innovations, flexible medication access, one-on-one clinical support, and excellent customer service.

  Scheduled Weekly Hours

  40

  Pay Range

  The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

  
  

  $34,500 - $47,400 per year

  
  

  This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

  Description of Benefits

  Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

• About the company

  Humana looks at every facet of your life and works with you to create a path to health that fits your unique needs

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