Pharmacy Finance and Claims Specialist

Knowledge, Skills, and Abilities

• Demonstrated ability to utilize various office productivity software.
• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
• The ability to exercise sound judgment and possess strong problem-solving skills.
• The ability to ask probing questions and obtain thorough and relevant information.
• The ability to deliver highly technical information to a variety of individuals.
• Knowledge of the most common brand and generic drug names.
• Knowledge of third-party prescription claims adjudication programs and processes.
• Knowledge of managed care principles and reimbursement policies and procedures.
• Knowledge of basic medical terminology and understanding of the National Drug Code (NDC).
• Knowledge of 340B program and regulations governing administration and compliance.
• Knowledge of Mississippi Board of Pharmacy and Federal regulations.
• The ability to regularly produce accurate, verified work.
• Must demonstrate the ability to manage multiple priorities or tasks, deliver timely and accurate work products with a customer service focus, and respond with urgency as required.
• Must demonstrate professional and ethical business practices, adherence to company
  standards, and a commitment to personal and professional development.
• Proven time management skills and the ability to work in a production focused environment.
• The ability to work independently.
• Ability to sit, stand, bend, lift, and move intermittently during the workday.
• Must perform all other duties as assigned.

Qualifications/Education Requirements

Must have a high school diploma or equivalent and preferably 1-2 years of experience in a pharmacy setting. Graduation with a 2–4-year degree from an accredited educational program is preferred. Knowledge and experience in the adjudication of pharmacy claims and Maximum Allowable Cost (MAC) appeals experience is highly desired.

Physical Demands

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Coastal Family Health Center is committed to working with and providing reasonable accommodation to qualified individuals.

Core Competencies

• Generating monthly statements, processing payments, and reconciling third-party claims through the pharmacy data system accounts receivable.
• Assisting the Accounting Department in collecting data for claims audits.
• Serve as a subject matter expert for complicated processing for prescriptions.
• Work cross functionally with other departments.
• Claims adjustments and review.
• Understanding of Medicare Part D, commercial insurance, and Medicaid.
• Adjudicating insurance claims and troubleshooting rejected claims.
• Completing prior authorization forms if necessary.
• Ensure compliance of 340B pharmacy and third-party billing practices.
• Providing prompt and professional customer service through phone calls and emails.
• Communication with insurance parties via inbound and outbound calls.
• Analyzing pre- and post- adjudication reports for training opportunities and compliance.
• Must possess a valid driver’s license, reliable transportation, and willingness to travel to different pharmacy locations as required.
• Performs other duties as requested and/or required.
• Upholds, complies with, and enforces the Core Principles and Code of Conduct.