3rd Party Plan Analyst

Overview

The 3rd Party Analyst is responsible for configuring 3rd party insurance setups within our proprietary system, and monitoring and evaluating events related to 3rd party claims. The 3rd party analyst will interact with appropriate departments to ensure integrity of third party claim information and provide pharmacy operations support. The position specializes in pharmacy claim billing and reimbursement detail. Analyst are considered experts in Medicare Part D, Medicaid, and Commercial insurance. The analyst will also assist with special projects and ad hoc assignments as needed.

Requirements

• Two or more years of experience as a Pharmacy Technician or in a billing position within a Health Care setting
• Required: One or more years of experience with Pharmacy or Health Data analysis and working in a Pharmacy, long-term or managed care setting

Schedule: Monday - Friday, 8:00am - 4:30pm

Our Benefits Include:

• Competitive pay
• Health, dental, & vision
• Company paid STD & LTD
• Paid Time Off
• Flexible Schedules
• Tuition Reimbursement
• 401k
• Employee Discount Program
• Daily Pay
• Pet Insurance 

Responsibilities

• Communicate effectively and professionally with 3rd party entities including Pharmacy Benefit Managers (PBM’s), pharmacy claim switches, and other vendors regarding claim or plan inquiries
• Understand various payer requirements and configure billing parameters within proprietary software to send online transactions to and from 3rd party insurance payers in accordance with HIPAA named standards set forth by the National Council for Prescription Drug Programs (NCPDP)
• Review 3rd party payer sheets for specific configuration details
• Construct telecom standard field specific templates for each payer
• Communicate with switching company to construct external pre and post claim edits to prevent claim denials and ensure proper reimbursement
• Send and receive contracts on behalf of the Director of 3rd Party Network Services
• Work with Compliance team to obtain, reissue, or renew Medicaid provider ID’s, and work with other internal teams across the organization
• Serve as subject matter expert (SME) on cross functional work groups
• Provide operational support and troubleshooting to resolve both internal and external inquiries
• Research and resolve complex billing issues with available resources and tools
  • This includes researching both denied and paid claim transactions, understanding root cause for denied claims or under reimbursement on paid claims, implementing methods to reduce such claims, or educating pharmacies on prevention opportunities
• Ensure all industry and/or payer related changes are communicated throughout the organization
• Independently and accurately manage workload in a timely manner with minimal direction
• Communicate when competing priorities cannot be managed independently
• Prepare recurring reports related to claim denials or payments
• Query, massage, and analyze small to medium sums of claim data
• Summarize and report findings to executive management or other internal teams
• Support project teams in the development of functional requirements
• Performs other tasks as assigned
• Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required. Each essential function is required, although reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Qualifications

Education/Learning Experience:

• Required: HS Diploma, GED, or equivalent experience
• Desired: Associate or Bachelor's degree

Licenses/Certifications:

• Desired: Pharmacy Technician 

Work Experience:

• Required: Two or more years of experience as a Pharmacy Technician or in a billing position within a Health Care setting
• Required: One or more years of experience with Pharmacy or Health Data analysis and working in a Pharmacy, long-term or managed care setting

Skills/Knowledge:

• Required: Excellent verbal and written communication skills; Excellent time management skills; ability to work independently and manage multiple/competing priorities; Proven ability to work with a high degree of accuracy and attention to detail; Proficient in all Microsoft  Word and Outlook; Demonstrated analytical skills, technical knowledge and creative problem solving techniques; Ability to effectively navigate ambiguous situations with limited direction; Advanced analytical skills with the ability to interpret and synthesize complex data sets; Able to handle high volume and significant workload
• Desired: Query building experience through use of Microsoft Access or other proprietary system; familiarity with long term care pharmacy or facility billing practices