Senior Transition Pharmacy Claims Professional - Humana
Dover, DE
About the Job
Become a part of our caring community and help us put health first
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 Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$63,400 - $87,400 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
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 Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$63,400 - $87,400 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Source : Humana