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PerformRx is a Pharmacy Benefits Manager (PBM) dedicated to clinical culture, boutique service and holistic solutions. Our mission is to help clients, providers and members use effective medication therapy to improve health and wellness. For over two decades, our focus has been on providing optimal service through a clinical culture which seeks to provide members with high quality care while ensuring our partners receive favorable costs. That culture is reflected in our employees — more than 80 percent of our staff members are Pharmacists and Pharmacy Technicians — and in the services we provide.
PerformRx is headquartered in Philadelphia. Our dedication to innovation and to providing the most efficacious outcomes is the core of our clinical culture and is the heart of PerformRx. PerformRx is a subsidiary of the AmeriHealth Caritas Family of Companies.
Summary:
The Pharmacy Network Operations Analyst supports business and initiatives undertaken by Pharmacy Network Operations by liaising with applicable line of business contacts to monitor, acquire, extract, manipulate, and evaluate/analyze data. The Analyst coordinates with intra-departmental and corporate resources to facilitate timely completion and communication of data gathering, data design and reporting activities. As part of the Pharmacy Network Operations team, the Pharmacy Network Operations Analyst supports new and existing market implementations and/or operations by assuring Provider data integrity, format consistency and load accuracy through validation methods and electronic tools. The incumbent will also serve as the lead operational reporting subject-matter expert (SME) within the company regarding pharmacy standard monitoring measures including pharmacy audit.
Responsibilities:
- Communicate report findings and observations, and collaborate with pharmacy management to resolve issues in a timely and efficient manner
- Analyze pharmacy network access claims data, applying knowledge of pharmacy policy and data mining techniques, to determine details of fraudulent, erroneous, or abusive billing activity on claims processing systems, GEO Access, and various pharmacy network client specific reporting
- Prepare claims sample and supporting documentation for the claim review (remote or onsite)
- Generate all GEO Access Reporting for the Pharmacy Network Department
- Prepare draft and final reports of the audit findings, including recommendations for corrective action, for delivery to the client and the claims administrator
- Support efforts to grow the revenue and profitability of our pharmacy network and claims auditing business
- Monitor updates and changes related to data requirements and reporting for internal and external customer.
- Collaborate and execute processes & procedures and process improvement initiatives/documentation
- Support pharmacy network upgrades to effectively and efficiently deliver results to all LOBs and new markets
- Collaborate and oversee directory work with print and online processes, on-demand and data pulls
- Support new business initiatives and implementation work for pharmacy network intelligence and RFPs
Education/Experience:
- Bachelor’s Degree preferred or equivalent experience required
- Minimum three (3) years of current/recent claims experience required
- Minimum three (3) years of current/recent managed health care experience required
- Minimum three (3) years of current/recent experience with Microsoft Access and Excel required
- Minimum five (5) years of current/recent managed healthcare experience required
- Requires:
- Proficient working knowledge of URAC and CMS network requirements
- Proficient working knowledge of Federal and State level auditing & network requirements
- Proficiency with software applications capable of provider-specific reports, such as network adequacy, payment rules, provider services and director
- Proficiency with healthcare claim adjudication standards and procedures including application of benefit plan designs, administrative services agreements, coordination of benefits, and subrogation provisions
- Understanding of and experience related to pharmacy claims payment configuration process/systems and its relevance/impact on network operations
- Formal training or equivalent experience in the effective use of reporting and querying software such as MS Excel, MS Access, and Visual Basics for Access, BI Query, and/or SQL
- In-depth knowledge of pharmacy operations Long-Term Care (LTC) and/or Specialty Pharmacy experience
- Claims processing and Provider data maintenance knowledge
- Outstanding analytical, assessment, investigative, problem-solving and project management skills
- Detail oriented with ability to manage multiple client assignments simultaneously
- Strong communication (listening, verbal and written), organization and time management skills
- Proficient in pharmacy provider data and deliverables related contract or regulatory procedures associated with assigned lines of business with current knowledge of changes and upgrades that affect the quality and accuracy of the products
- Ability to adapt to fluctuating situations and perform work of a detailed and error-free nature
- Ability to effectively interact with all levels of staff and management
- Able to work independently
- Ability to define problems, collect data, establish facts and draw valid conclusions
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Robbinsville, NJ
Full Time