Benefit Coding Specialist

Overview

The Benefit Coding Specialist will be responsible for the accurate and timely implementation of the Benefit Coding of new VerusRx clients, the ongoing build of benefit plans into the claim adjudication platform, and the testing of the benefit design after the coding has been completed. This individual will assist with performing quality assurance reviews on recently implemented coding and updates and serve as the subject matter expert in Benefit Coding into RxAgile (or potentially other similar platforms).

Job Description

• Configure benefits into the claim adjudication platform, including benefit inclusions/exclusions, copay updates, and more.
• Performs research and troubleshoots inquiries or issues related to claims adjudication, including claim rejects or coding errors.
• Analyze coding requests and work with internal teams to obtain the accurate plan design needed to code to client intent.
• Implement new clients’ plan designs, maintain existing plan designs, and assist with pricing and pharmacy network coding in the pharmacy claim adjudication platform.
• Work closely with VerusRx Clinical Team to maintain formularies and clinical program offerings within the adjudication system.
• Design, develop, and execute testing for prescription benefit plans after completion of implementation.
• Work closely with cross-functional teams to gather relevant data and perform testing to ensure the accuracy of benefit calculations, eligibility criteria, and plan design.

Qualifications

• High school diploma or GED required; Bachelor’s Degree preferred
• 2-5 years of related PBM experience
• Knowledge of systems: MS Office; Excel, PowerPoint, Project and Outlook; experience in RxAgile preferred
• Knowledge of PBM industry is required.

Job Skills

• Ability to problem-solve in a fast-paced environment
• Extensive knowledge of pharmacy benefit configuration and claim processing requirements
• Strong attention to detail
• A well-organized and self-directed individual who demonstrates a strong understanding of project management
• Thorough critical-thinking skills

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