Pharmacy Claims Manager-Overpayment

Profile

Description

The Manager, Pharmacy Claims works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals. The manager will lead a team of 4-8 individuals and assist with the development and implementation of the following overpayment programs: Medicare Secondary Payer, Commercial COB, Commercial vs Medicare Part B and Commercial Retro-term. May include additional overpayment processes related to Part A vs Part D, Part B vs Part D and review of pharmacy claims containing invalid claim elements.

Responsibilities

The Manager, Pharmacy Claims analyzes and answers inquiries regarding pharmacy claims adjudication, including method of payment, co-pay or deductible amounts, and/or reason for denial. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross-departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.

Job Duties to include the following:


Leading a team of four to eight associates
Managing inventory, and assigning work
Assisting in the development of analytics and reports needed to support the day- to- day business.
Assist in establishing solid metrics
Facilitate training and onboarding new associates
Collaborate on creation of training materials
Assist with payer to payer system buildout
Provide daily guidance and oversight
Effectively collaborate with other Humana departments and PCAR teams and maintain frequent contact with other managers across the department
Aid in the development of analytics and reports needed to support the day to day business
Assist with developing and documentation of process
Participate in implementation of new auditing system
Will be responsible to ensure system includes all aspects of new work streams


Required Qualifications


Bachelor's Degree and 6 years Pharmacy Claims experience, or equivalent
2 years of direct leadership experience and demonstrated ability to lead, coach and mentor teams
Data driven; strong business acumen and analytical
Comprehensive knowledge of all Microsoft Office applications, including Word, Excel and PowerPoint
Exceptional organizational & time management, interpersonal, written, and oral communication and presentation skills
Ability to collaborate with multiple cross functional teams & vendors; internally and externally
Strong ability to multi-task, meet deadlines, and follow-up timely
Ability to compile, analyze, interpret and integrate information and to prepare and present complex reports, statements, policies & procedures
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Ability to travel to up to 25%


Preferred Qualifications


Reside in the Louisville area, or within a commutable distance
Previous experience with pharmacy benefits management
Knowledge/experience working with SQL (via MS SQL Server, Oracle, PL/SQL or other)
Knowledge/experience working with Microsoft Access
Pharmacy Tech experience
Previous experience with Medicare Secondary Payer
Experience with pharmacy overpayment processes


Additional Information

Interview Format:

As part of our hiring process for this opportunity, we may use an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Montage Voice allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected for a first-round interview, you may receive an email correspondence inviting you to participate in a Montage Voice/Text interview. In this interview, you will listen/read a set of interview questions over your phone or computer and you will provide recorded/typed responses to each question. You should anticipate this interview to take about 15 minutes. Your recorded/text interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.


Alert:


Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from **** with instructions to add the information into the application at Humana's secure website.

Scheduled Weekly Hours

40

Company info

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