American Health Partners · 23 hours ago
Pharmacy/Billing Technician
Franklin, TN
Full-time
Hybrid
Entry, Mid Level
2+ years expAmerican Health Partners is seeking a Pharmacy Technician responsible for managing claims adjudication and operations for their Medicare Advantage Institutional Special Needs Plan. The role involves reviewing pharmacy claims, collaborating with pharmacy teams, and ensuring compliance with regulations while facilitating prior authorizations and addressing claim issues.
Elder CareHealth CareHome Health CareNursing and Residential Care
Responsibilities
Review daily point-of-service (POS) pharmacy claims, resolve actionable items, track, and provide reporting
Investigate and resolve pharmacy claim rejections, reversals, and payment discrepancies in real time
Collaborate with external pharmacy and claims teams to ensure accurate claim adjudication and payment
Submit and track claim overrides when appropriate and compliant with plan and CMS guidelines
Ensure proper coordination of benefits (COB), hospice billing considerations, and Part A/B vs Part D determinations when applicable
Facilitate the prior authorization process by working with prescribers, pharmacies, and internal clinical staff
Gather and submit required documentation for PA review and ensure completeness to minimize delays
Monitor PA status and proactively communicate determinations and next steps to pharmacies and providers
Serve as primary billing and claims contact for contracted network and long-term care pharmacies
Communicate professionally with pharmacy billing teams, prescribers, and facility staff to resolve claims issues
Educate pharmacies and provider offices on billing requirements, formulary limitations, and plan processes
Support transitions of care by ensuring medication access and clean claim processing for new or discharged members
Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies
Accurately document all claim interventions, communications, and resolutions in the plan’s system
Assist with internal audits, reporting, and quality improvement initiatives related to claims and billing
Identify trends in claim rejections or PA delays and escalate systemic issues to leadership
Monitor daily billing and claims work queues and meet productivity and turnaround time expectations
Participate in cross-functional meetings with pharmacy operations, clinical, and provider relations teams
Support process improvement initiatives to enhance claims efficiency and member access to medications
Serve as a liaison with Enrollment Department to assure appropriate member eligibility processing
Recognize formulary requirements: prior authorization (PA), Step Therapy (ST), Quantity Limit (QL) and understand NCPDP reject codes
Coordinate clinical reporting
Follow-up and solve open items in a timely manner
May be assigned to work on special projects and business initiatives
Other duties as assigned
Qualification
Required
High school diploma or equivalent
Minimum of 2 years as a Pharmacy technician, long term care, or health plan experience
Experience in planning and implementation
Experience working pharmacy claims, rejections, and PA's
Proficient with Microsoft Suite applications
Ability to navigate multiple systems
Strong analytical skills
Proficient communication and presentation skills
Adhere to Centers of Medicare and Medicaid Services (CMS) regulations and compliance requirements
Successful completion of required training
Preferred
Pharmacy Technician certification preferred
Company
American Health Partners
American Health Partners provides home health care, senior living, and rehabilitation services.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Jeff Bogle
CFO
Recent News
Modern Healthcare
2024-10-30
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