AmeriHealth Caritas Service Delivery - Pharmacy Benefit Claims Analyst in Philadelphia, Pennsylvania

Service Delivery - Pharmacy Benefit Claims Analyst

Location: Philadelphia, PA

Telecommuter?: Yes

ID**: 14233

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .

Summary : To maintain, review, and provide consultation on basic to moderately complex customer pharmacy benefits. The Benefit Claims Analyst also analyzes pharmacy claims reports to identify trends, issues, and present recommendations.

Responsibilities:

  • Maintains current knowledge of Medicare requirements related to Part D Chapters 5, 6, and 14, as they pertain to pharmacy benefits and pharmacy claims adjudication.

  • Researches pharmacy benefit questions and claims related inquiries for Medicaid, Exchange, and Medicare plans.

  • Work with various levels of requests with varying degrees of escalation from internal and external departments to make recommendations for fulfillment of basic to moderately complex benefit requests.

  • Documents benefit designs submission to the claims-processing vendor and provide oversight and maintenance of this documentation.

  • Utilizes pharmacy claims-processing software to test pharmacy benefits, process claim transactions (adjustments/re-work), investigate issues, and provides strategic guidance on how to improve claims processing to management.

  • Prepares test plans, develops testing scenarios, and executes testing strategies.

  • Investigates reported claims defects and provides detailed summaries of analysis and all available solutions for immediate mitigation.

  • Analyzes and reports pharmacy claims processing activity and trends for appropriateness based on benefit design requirements from the customer and also for providing recommendations to management.

  • Reviews and writes comprehensive reports, identifies alternatives, and makes recommendations to management.

  • Participation and leadership in audits related to pharmacy benefits and claims-processing

  • Performs other related duties and projects as assigned by the department Director or Manager of Pharmacy Benefits

  • 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, policies 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:

  • High School Diploma or equivalent required

  • Bachelor’s degree preferred or equivalent work experience

  • CPhT or PTCB Certification preferred

  • Minimum three (3) years of PBM, pharmacy operations or claims processing experience required

  • Progressive and focused work experience in continuous improvement initiatives, project management and/or organizational development

  • Strong analytical, planning, organizational, communication and time management skills

  • Strong research skills including gathering and analyzing data from multiple sources

  • Effective technical writing skills

  • Working in a cross-functional team environment

  • Ability to interpret and apply rules, regulations, policies, and procedures

  • Effective interpersonal and communication skills including tact and diplomacy

  • Effective organizational and planning skills with attention to detail and follow through

  • Ability to maintain confidentiality

EOE Minorities/Females/Protected Veterans/Disabled