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DescriptionThe Senior Pharmacy Claims Professional oversees processes and ensures accuracy for pharmacy point of sale coordination of benefits (COB) adjudicated claims. The Senior Pharmacy Claims Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.ResponsibilitiesThe Senior Pharmacy Claims Professional analyzes, monitors and enhances processes and claims adjudication logic as it pertains to pharmacy COB point of sale claims. Works closely on cross collaborative project teams, with internal and external partners, to identify impact, ensure appropriate project requirements and test projects end to end. Ensures processes are documented, reviewed for appropriateness and compliance and monitored regularly. Begin to influence department's strategy. Makes decisions on moderately complex to complex issues, regarding technical approach for project components and gain a broad base of claims knowledge. Exercises considerable latitude in determining objectives and approaches to assignments. You will have the opportunity to use your expertise in data analysis and problem solving to ensure compliance with state and federal regulations. Responsibilities include:Subject matter expert for pharmacy COB processes and claims processing logic
Main speaker during CMS Program audits and compliance mock audits
Ensure compliance with all Federal and state requirements
Create, update and maintain various reports and policy/procedure documents
Lead projects with internal/external areas related to required process or logic changes
Other duties as assigned
Required Qualifications3 - 5 years of data analysis & problem solving regarding process and work flow concepts
Aptitude in Microsoft Office applications, including Access, Word, Excel and PowerPoint
Demonstrated proficiency working with SQL (via MS SQL Server, PL/SQL)
Strong consultative skills and relationship building skills
Strong verbal and written communication skills
Strong organizational and time management skills
Ability to handle multiple tasks, meet deadlines, and follow-up timely
Ability to work in a fast paced, dynamic and changing environment while managing multiple projects simultaneously
Strong attention to detail
Pharmacy or Medical claims experience
Preferred QualificationsBachelor's degree
Pharmacy point of sale logic experience
Project testing including building scenarios
Proven experience with process engineering
CMS Chapter 14 knowledge
Additional InformationMust be willing to work in EST
Scheduled Weekly Hours40
