Abrar Admin

American Health Plans

<div>JOB SUMMARY: 
 
The Pharmacy Technician for American Health Plans is responsible for activities related to member access in the area of claims adjudication appropriateness and operations performed by the Plan&rsquo;s Pharmacy Benefit Manager for a Medicare Advantage Institutional Special Needs Plan (I-SNP).

ESSENTIAL JOB DUTIES:

To perform this job, an individual must perform each essential function satisfactorily, with or without a reasonable accommodation.
<ul>
<li>Review daily point-of-service (POS) pharmacy claims, resolve actionable items, track, and provide reporting</li>
<li>Investigate and resolve pharmacy claim rejections, reversals, and payment discrepancies in real time.</li>
<li>Collaborate with external pharmacy and claims teams to ensure accurate claim adjudication and payment.</li>
<li>Submit and track claim overrides when appropriate and compliant with plan and CMS guidelines.</li>
<li>Ensure proper coordination of benefits (COB), hospice billing considerations, and Part A/B vs Part D determinations when applicable.</li>
<li>Facilitate the prior authorization process by working with prescribers, pharmacies, and internal clinical staff.</li>
<li>Gather and submit required documentation for PA review and ensure completeness to minimize delays.</li>
<li>Monitor PA status and proactively communicate determinations and next steps to pharmacies and providers.</li>
<li>Serve as primary billing and claims contact for contracted network and long-term care pharmacies.</li>
<li>Communicate professionally with pharmacy billing teams, prescribers, and facility staff to resolve claims issues.</li>
<li>Educate pharmacies and provider offices on billing requirements, formulary limitations, and plan processes.</li>
<li>Support transitions of care by ensuring medication access and clean claim processing for new or discharged members.</li>
<li>Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies.</li>
<li>Accurately document all claim interventions, communications, and resolutions in the plan&rsquo;s system.</li>
<li>Assist with internal audits, reporting, and quality improvement initiatives related to claims and billing.</li>
<li>Identify trends in claim rejections or PA delays and escalate systemic issues to leadership.</li>
<li>Monitor daily billing and claims work queues and meet productivity and turnaround time expectations.</li>
<li>Participate in cross-functional meetings with pharmacy operations, clinical, and provider relations teams.</li>
<li>Support process improvement initiatives to enhance claims efficiency and member access to medications.</li>
<li>Serve as a liaison with Enrollment Department to assure appropriate member eligibility processing</li>
<li>Recognize formulary requirements: prior authorization (PA), Step Therapy (ST), Quantity Limit (QL) and understand NCPDP reject codes</li>
<li>Coordinate clinical reporting</li>
<li>Follow-up and solve open items in a timely manner</li>
<li>May be assigned to work on special projects and business initiatives</li>
<li>Other duties as assigned</li>
</ul>
JOB REQUIREMENTS:
<ul><li>Proficient with Microsoft Suite applications</li>
<li>Ability to navigate multiple systems</li>
<li>Strong analytical skills</li>
<li>Proficient communication and presentation skills</li>
<li>Adhere to Centers of Medicare and Medicaid Services (CMS) regulations and compliance requirements</li>
<li>Successful completion of required training</li>
</ul>
REQUIRED QUALIFICATIONS:
<ul><li>Education:
<ul><li>High school diploma or equivalent</li>
</ul></li><li>Experience:
<ul><li>Minimum of 2 years as a Pharmacy technician, long term care, or health plan experience</li>
<li>Experience in planning and implementation</li>
<li>Experience working pharmacy claims, rejections, and PA&rsquo;s</li>
</ul></li><li>License/Certification(s):
<ul><li>Pharmacy Technician certification preferred</li></ul></li></ul></div>

Pharmacy/Billing Technician

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American Health Plans

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Pharmacy/Billing Technician