Report to: Manager, Pharmacy Benefits Relations
Location: Independence Rd/George Rd
Type: Hourly/ Non-Exempt
Coordinates and controls the workflow occurring in and out of the department. Serves as a liaison between WellCare and its Pharmacy Benefit Manager (PBM) for all aspects of pharmacy claims processing issues. Coordinates and supports audit related activities, specifically surrounding information gathering and analytical evaluation of preliminary audit results. Partners closely and coordinates with other pharmacy and functional departments on a frequent basis to ensure synergies and cross-departmental effectiveness.
Additional Responsibilities:Candidate Education:
- Reviews and tracks all aspects of pharmacy claims processing for completeness and coding accuracy.
- Manually updates PBM eligibility to sync with WellCare enrollment systems on a daily basis where updates are not made available through batch loading in the PBM system.
- Responsible for making updates in the PBM system as part of Medicare Part D PDE reconciliation.
- Maintains the integrity of the data loaded in to the PBM.
- Performs ongoing claims testing to ensure accuracy of adjudication at Point of Service.
- Researches, troubleshoots and resolves claims issues with internal and external partners.
- Escalates issues to the PBM account team, where appropriate, and seeks follow-ups, as necessary until resolution.
- Serves as primary point of contact to the escalated Pharmacy call center support staff on PBM issues.
- First tier point of contact for information gathering in audits relating to pharmacy claims processing, including audits by state and federal agencies.
- Provides claims research, analysis, and support during audits.
- Tracks requests coming into the department and evaluates trends; involving others as necessary.
- Oversees the daily, weekly, and monthly receipt of Third Party Vendor files.
- Supports leadership and the department on a wide array of PBM related initiatives, tasks and projects related to all aspects of the plans' pharmacy benefit for all lines of business.
- Follows all state and federal regulations and contractual requirements, including record retention requirements.
- Performs other duties as assigned.
- Required An Associate's Degree in a related field
- Required or equivalent work experience
- Preferred A Bachelor's Degree in a related field
- Required 2 years of experience in pharmacy or managed care environments
- Preferred Other familiarity with the pharmacy software utilized by WellCare and the PBM is a plus.
Licenses and Certifications:
- Intermediate Ability to communicate and make recommendations to upper management
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate Ability to represent the company with external constituents
- Advanced Ability to work in a fast paced environment with changing priorities
- Intermediate Demonstrated analytical skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated organizational skills
- Intermediate Demonstrated problem solving skills
- Intermediate Knowledge of healthcare delivery
A license in one of the following is required:
- Preferred Certified Pharmacy Technician (CPhT)
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Outlook
- Required Intermediate Healthcare Management Systems (Generic)