Humana Pharmacy Claims Representative in Cincinnati, Ohio
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.
This is a work at home opportunity.
Schedule : We have three positions and shifts available
Schedule 1: Monday through Friday 10:15am - 6:45pm with every 4th weekend rotations (Sun and Saturday)
Schedule 2: Monday through Friday 11:15am - 7:45pm with every 4th weekend rotations (Sun and Saturday)
Schedule 3: Monday through Friday 12pm - 8:30pm with every 4th weekend rotations (Sun and Saturday)
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 over 450 customers and nearly 100,000 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.
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):
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
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
Strong verbal and written communication skills, including the ability to tailor communication to audience
Problem-solving skills and ability to follow through on tasks assigned
Ability to handle multiple tasks, meet deadlines, and follow-up timely
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Required Education and/or Experience:
At least 1 year of Pharmacy Technician experience
Knowledge of pharmacy claims and adjudications
High school diploma
Dispensing system experience
CPhT or EXCPT
Covid Vaccination Policy
We will require full COVID vaccination for this job as we are a healthcare company committed to putting health and safety first for our members, patients, associates and the communities we serve.
If progressed to offer, you will be required to provide proof of full vaccination or documentation for a medical or religious exemption consideration where allowed by law.
Scheduled Weekly Hours
- Humana Jobs