Job Posting for Network Operation Analyst - PerformRx - Remote at Amerihealth
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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.
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
Salary.com Estimation for Network Operation Analyst - PerformRx - Remote in Philadelphia, PA
$68,235 to $86,923
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