Senior Transition Pharmacy Claims Professional

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 The Senior Pharmacy Claims Professional adjudicates pharmacy claims and process pharmacy claims for payment. The Senior Pharmacy Claims Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Senior Pharmacy Claims Professional oversees processes and ensures accuracy for pharmacy point of sale transition adjudicated claims. The Senior Pharmacy Claims Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Pharmacy Claims Professional analyzes, monitors and enhances processes and claims adjudication logic as it pertains to pharmacy transition point of sale claims. Works closely on cross collaborative project teams, with internal and external partners, to identify impact, ensure appropriate project requirements and test projects end to end. Ensures processes are documented, reviewed for appropriateness and compliance and monitored regularly. Begin to influence department’s strategy. Makes decisions on moderately complex to complex issues, regarding technical approach for project components and gain a broad base of claims knowledge. Exercises considerable latitude in determining objectives and approaches to assignments. You will have the opportunity to use your expertise in data analysis and problem solving to ensure compliance with state and federal regulations. Responsibilities include:

• Subject matter expert for pharmacy transition processes and claims processing logic.
• Speaker during CMS Program audits and compliance mock audits
• Ensure compliance with all Federal and state requirements.
• Create, update and maintain various reports and policy/procedure documents.
• Lead projects with internal/external areas related to required process or logic changes.
• Other duties as assigned.  

Use your skills to make an impact
 

Required Qualifications

• 3 - 5 years of data analysis & problem-solving regarding process and workflow concepts
• Aptitude in Microsoft Office applications, including Access, Word, Excel and PowerPoint
• Demonstrated proficiency working with SQL (via MS SQL Server, PL/SQL)
• Strong consultative skills and relationship building skills
• Strong verbal and written communication skills
• Strong organizational and time management skills
• Ability to handle multiple tasks, meet deadlines, and follow-up timely
• Ability to work in a fast paced, dynamic and changing environment while managing multiple projects simultaneously
• Strong attention to detail

Preferred Qualifications

• Bachelor's degree
• Pharmacy point of sale logic experience
• Project testing including building scenarios
• Previous experience with pharmacy claims
• Proven experience with process engineering

Scheduled Weekly Hours

40

Pay …