Summary of Job
Serve as pharmacy systems coding subject matter expert for Prior Authorization with a focus on medical drug claim processing, review of utilization management, PA processing, and appeals; as well as the following: claims processes and JUDI interoperability with FACETS edits and other connection troubleshooting. Provide technical and subject matter expertise support for implementations and day to day operations of Pharmacy functions and vendor coordination. Support operations for file transfer systems (configuration, deployment, pharmacy management and medical benefits, eligibility). Support operations for system integration, including monitoring files and transitions, fallout, and root cause analyses. Execute non-clinical Appeals from post claim edit process, and consistently maintain queue
Responsibilities
- Collaborate in defining, gathering, reviewing, and editing business requirements for system updates, enhancements and migrations for claims projects.
- Perform solution analysis review and provide concise direction to ensure that the proposed system solution meets established business protocols, and any mandates and compliance guidelines.
- Partner with business analysts, business users and source system experts to produce claim processing output consistent with meeting overall goals.
- Review daily, pended medical drug claims for accuracy.
- Identify and implement solutions to support automation of claims or resolve with manual intervention.
- Collaborate with clinical, formulary, payment integrity and other key players to ensure issues are accurately defined with an appropriate solution.
- Submit and track medical claims system configuration requests related to RPC (Reimbursement Policy Committee) decisions, ensuring timely implementation and alignment with approved policy guidelines.
- Work with business units to develop test strategies and scenarios from business requirements.
- Accurately interpret and translate strategies and scenarios into test plans.
- Analyze requirements, test documents and acceptance criteria which will effectively find defects that may exist in claims processing.
- Act as a liaison and subject matter expert for day to day medical drug system-related technical questions and/or issues.
- Troubleshoot and track all concerns on unpaid claims, working with key stakeholders and respond to all appropriate parties effectively within a timely manner.
- Provide written progress report to leadership regarding the status of deliverables, issues, problems and corrective actions taken.
- Perform other related tasks as directed or required
Qualifications
- Bachelor’s degree required
- 4 – 6+ years of relevant, professional work experience (Required)
- 2+ years’ experience in one or more of the following: claims processing, pharmacy/coding, utilization management (Required)
- Experience in a healthcare environment (Required)
- Proficiency with MS Office - Word, Excel, Access, PowerPoint, Outlook (Required)
- Advanced reporting system experience/knowledge - SAS, Oracle, etc. (Preferred)
- Track record of successfully managing multiple tasks/projects with competing priority levels/deadlines (Required)
- Ability to understand complex technical system requirements and translate into simple business language (Required)
- Excellent communication skills - verbal, written, presentation, reporting, interpersonal (Required)
- Attention to detail; ability to think critically; ability to identify, quantify, analyze and resolve issues (Required)
Additional Information
- Requisition ID: 1000003227
- Hiring Range: $68,040-$118,800
