The Pharmacy Claims Auditor adjudicates pharmacy claims and process pharmacy claims for payment. The Pharmacy Claims Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Humana Pharmacy Operations has a unit dedicated to the oversight of Medicare and Commercial Direct Member Reimbursement (DMR) claims processes. This area ensures the timeliness and quality for Pharmacy DMR claims.
The DMR Pharmacy Claims Auditor analyzes and answers inquiries regarding pharmacy claims adjudication, including method of payment, co-pay or deductible amounts, and/or reason for denial. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Technology that will be utilized includes Outlook (including Secure Email), Excel, Access Database, PowerPoint, Humana CCP2, Argus IPNS.
The DMR Pharmacy Claims Auditor must become familiar with all Commercial and internal procedures related to DMR processing requirements. The DMR analysts on this team are generally responsible for:• Auditing DMR claims• Monitoring claims for timeliness• Overall monitoring of volume/quality of DMRs as well as claims analysis• DMR projects as needed
Strong working knowledge of Microsoft Excel is required. Daily part of job is pulling data from Humana system into Excel – using pivot tables and creating reports.Attention to detail with the ability to handle multiple prioritiesAbility to work independently and within a team setting
Comprehensive knowledge of all Microsoft Office applications, including Access, Word, Excel and PowerPoint
Strong verbal and written communication skills, including the ability to tailor communication to audience
Strong organizational and time management skills
Ability to handle multiple tasks, meet deadlines, and follow-up timely
Bachelor's degree or equivalent experience
CCP and RxNova experience
Previous experience with pharmacy benefits management
Knowledge/experience working with SQL (via MS SQL Server, Oracle, PL/SQL or other)
Pharmacy Tech experience
Scheduled Weekly Hours
Equal Opportunity Employer
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