What are the responsibilities and job description for the Claims and Benefits Auditor position at Geisinger?
- Monitors pharmacy and medical claims processing as it relates to the relationship with the external pharmacy claims processor. Assists in the design, audit and functional roll-out of new Pharmacy Initiative products.
- Performs quarterly audits to ensure compliance with multiple benefit designs.
- Documents and reports the findings to department leadership.
- Reports and follows up on any claims processing discrepancies found by communicating the proper direction in a systematic fashion to the external pharmacy claims processor.
- Reviews all specialty vendor claims to ensure proper prior authorizations have been entered in the claims processing system.
- Corrects any errors that are found. Analyzes and audits specialty vendor data as needed.
- Recommends policy and procedure changes to ensure proper reimbursement and provide for efficient processing of claims. Serves as the liaison between departments within the Geisinger system.
- Provides support for development of policies that serve as an educational tool for Pharmacy Claims Operations.
- Provides examples of incorrect authorizations to leadership as needed, so they can educate the staff as needed.
- Enters prior authorizations for special pharmacy programs, as well as special pharmacy formulary changes.
- Assists in audits by outside agencies, third party payors and Internal Audit Departments upon request.
- Track and report monthly analysis of corrected claims processing errors and associated savings. Serve as point of contact to communicate special client claims processing needs.
Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
*Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).
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