Call Center Pharmacy Claims Technician

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Job Information

Humana

Call Center Pharmacy Claims Technician

in

Troy

Michigan

Description

Job Description Summary

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 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 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.

Schedule:

Monday through Friday 2:30PM to 11:00PM ET, with every 4th weekend rotation (Sat & Sun - off by 8 PM ET)

Location:

Remote USA

- Pharmacy Technician license is required if the BOP requires licensing for techs in your state.

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

Required Qualifications:

Less than 5 years of data analysis & problem solving skills

Comprehensive knowledge of all Microsoft Office applications, including Access, Word, Excel and PowerPoint

Strong verbal and written communication skills, including the ability to tailor communication to audience

Strong organizational and time management skills

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

Preferred Experience:

PBM experience

Dispensing system experience

CPhT or EXCPT

High School Diploma or GED

Claims experience

Work-At-Home Requirements

WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Additional Information

COVID 19 Vaccination:

For this job, associates are required to be fully COVID vaccinated (preferred) or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. 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 commit to testing protocols OR  

Provide proof of applicable exemption including any required supporting documentation

​​Medical, religious, state and remote-only work exemptions are available.

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 for a first round interview, you will receive an email/text correspondence inviting you to participate in a Modern Hire interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

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.

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com