Pharmacy Benefits Claims Analyst - Remote

Summary:

To maintain, review, and provide consultation on basic to moderately complex customer benefits. The Benefit Claims Analyst also analyzes claims reports to identify trends, issues, and present recommendations. 

*** OPEN TO CANDIDATES NATIONWIDE ***

Responsibilities:

• Maintains strong knowledge of Commercial and Exchange-Related Benefit Designs including a familiarity with Commercial Benefits Configurations with both Medical and Pharmacy-Combined Benefit Designs.  
• Maintains knowledge of Medicare and Medicaid-related benefit designs, including knowledge of CMS guidance and regulations applicable to Pharmacy Benefits. 
• Maintains knowledge of Coordination of Benefits (COB) and determining pharmacy payment liability between multiple payers, including Medicare, Medicaid and Commercial Pharmacy Benefits.
• Researches benefit and claims related inquiries from PerformRx clients and internal departments. 
• Makes recommendations for fulfilment of basic to moderately complex benefit requests, including presenting these recommendations to PerformRx management and clients upon request.
• Organizes and documents benefit design specifications in a standardized, client-facing format for submission to the claims processing vendor. 
• Prepares test plans, scenarios, and executes manual and batch testing in User-Acceptance Testing and Production/Live Testing environments in the claims processing software.
• Monitors and reports claims activity based upon benefit set-up to ensure accurate processing according to the approved requirements from the client.
• Troubleshoots reported claims defects and provides detailed summary of analysis and all available solutions for immediate mitigation with the Claims Processor. 
• Processes claims transaction requests (rework).
• Makes recommendations to management based upon trend analysis.
• Reviews and writes comprehensive reports, identifies alternatives, and makes recommendations to management and clients, upon request.
• Participation including leading of audits related to benefit or claims activity.
• Performs other related duties and projects as assigned by the Managers or department Director as required.

Supports and carries out the PerformRx Mission & Values.  

• Adheres to all AmeriHealth Caritas and PerformRx policies and procedures. 
• Maintains a current knowledge base of PerformRx programs, services, policy and procedures.  
• Regularly reviews and adheres to standard operating guidelines, desktop procedures, checklists, templates, and memorandums issued to the department. 

Creates and supports an environment which fosters teamwork, cooperation, respect and diversity.  

• Establishes and maintains positive communication and professional demeanor with PerformRx employees and customers at all times. 
• Demonstrates and supports commitment to corporate goals and objectives.

Education/Experience:

• Bachelor’s Degree preferred or equivalent work experience
• Active/current National Pharmacy Technician Certification (ExCPT, NCCT or PTCB) preferred
• Minimum three (3) years of Pharmacy Benefit Manager (PBM), pharmacy operations, and/or claims processing experience required
• Progressive and focused work experience in continuous improvement initiatives, project management, and/or organizational development