Title of Job: Pharmacy Member Services / Claims Processing Representative
We are hiring a Pharmacy Member Services / Claims Processing Representative for our Fortune 100 healthcare client in Montgomery, Alabama. Someone with previous experience in a call center or customer service rep (CSR), in healthcare, or within the pharmacy field or as a pharm tech is ideal.
Schedule / Hours: Monday-Friday / Training is 3 weeks from 8am- 5pm after training Start times between 12:00pm - 2:00pm and End Times between 9:00pm - 11:00pm
Status: Full Time
Location: Montgomery, AL
Effective Date / Tentative Start Date: Interviewing Immediately
This is the primary service-level position in a business to business multimedia PBM (Pharmacy Benefit Management) contact center.
The Member Services Rep serves as an initial point of contact to clients, nurses, pharmacies and physicians for inbound and outbound calls, faxes, e-mails, files and orders.
The Member Services Rep also handles multimedia contacts from nurses authorizing payment for medications for hospice patients which must be entered into a web-based database within required turnaround times.
Accuracy and knowledge of various operating procedures for different customers is a must.
Additionally, customer service receives multimedia contacts from retail and long-term care pharmacies requiring claims processing assistance, reimbursement disputes, and contract requests.
Representatives must review all claim data and authorizations on file to resolve rejection issues.
Day-to-day activities include, but are not limited to, all the essential functions listed below:
- Serve as initial point of contact to all incoming patient profiling, medication updates by pharmacies, nurses and other healthcare provider.
- Utilize multi-media functions (phone calls, faxes, and e-mail and integration files) to accurately input patient profile eligibility, medical history, clinical data, and updates into company operation platforms.
- Assist pharmacies in claims processing by providing information needed to process claims and researches all information related to pharmacy rejections.
- Process medication overrides for dosage changes or RTS (refills too soon), etc.
- Input manual claim data into the database on claims outside of processing window.
- Input appropriate claim processing call tracking notes with each call received.
- Provide patient medication profiles to facility pharmacies.
- Troubleshoot and resolve pharmacy related issues for Client Services.
- Input appropriate call-tracking notes with each call, fax, e-mail, or integration received.
- Transfer clients to clinical pharmacists for consults and create work order tickets and consult notes for pharmacist request.
- Assign coverage, transfers patients, or trouble shoots rejections as directed by clinical pharmacists.
- Work all assigned discharges and censuses from the Discharge Data Base.
- Implement new clients into the system for startup and quality check for accuracy and completeness.
- Accurately complete special projects assigned by management.
- Exhibit compliant and ethical behavior in the performance of job responsibilities, including complying with all applicable federal and state laws and regulations, company Code of Conduct, Business Ethics Policies and Procedures and other policies and procedures applicable to position.
- Actively participate in United Healthcare’s Compliance and Ethics Program, including attending annual compliance and ethics training and reporting suspected violations of the law or Catamaran’s policies and procedures.
- Follow all policies and procedures relating to job responsibilities.
- Perform any and all other duties and tasks as assigned by management to meet corporate objectives.
- Meet or exceed departmental performance standards and Provides world class customer service.
What qualifications do I need to have?
- Must have a High School diploma or equivalent. College or technical training a plus.
- Knowledge of proper telephone etiquette; previous call center experience preferred.
- Must have attention to detail with excellent problem solving and multi-tasking skills
- Computer literacy / data entry skills are required and proficiency in Microsoft Word, Outlook, and Excel
- Excellent written and verbal communication skills are required.
- Experience with image display software and web-based data entry software.
- Knowledge of Medical Terminology and ICD-10 Codes preferred.
- Knowledge of drug therapies. (Generic/Brand names, drug classes, sigs)
- Basic math and analytical skills.
- Possess a positive attitude and strong work ethic.
- Ability to work in a team environment and promote teamwork.
- Need to be able to work a flexible schedule including nights and weekends.
- Education and Experience
- Previous pharmacy technician experience highly desired, certification or licensure highly desired and/or related PBM business experience with knowledge of long term care pharmacy billing.
What Will My Day Look Like?
- We offer a competitive weekly salary and an opportunity for ongoing development that will further your career in the healthcare industry.
- Participate in various projects to help you grow in your career path in the fast-paced healthcare industry.
- You, your team and your manager will share goals, customer feedback and metrics to help you reach all of your weekly goals.
- Attend staff meetings and participate in discussions
- Required to maintain confidentiality and security of documents.
The CSI Companies is a recruiting firm established in 1994 that has been awarded “Best of Staffing” for 5 years in a row. We provide outstanding services to the world’s leaders in the healthcare field as well as other organizations. For consideration, please submit your resume with all of your relevant experience included on it for immediate consideration. Only those candidates identified for an interview will be contacted.
- Weekly pay
- Medical, dental, and vision coverage
- Voluntary Life and AD&D coverage
- Paid Training
- Opportunity for advancement upon performance and availability
Energize your career with one of Healthcare’s fastest growing companies.
No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.