Address
Form of workResponsibilities:
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.
Education/ Experience:
Other Skills:
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.
- 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 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.
- CPhT certification preferred.
- 3 to 5 years PBM, pharmacy operations, or claims processing experience required.
Other Skills:
- Progressive and focused work experience in continuous improvement initiatives, project management, and/or organizational development.
