Administrator, Pharmacy Reimbursement

Navitus Health Solutions, LLC

118d • $47,309 - $56,321

About The Position

Navitus Health Solutions is seeking a Pharmacy Reimbursement Administrator to join our team! The Pharmacy Reimbursement Administrator (PRA) works in partnership with the Provider Relations Coordinators, IT Client Operations, and others to continually review, monitor, and update procedures to improve efficiencies of claims adjudication administration. The PRA will test and review pharmacy networks to ensure that claims are adjudicating per Navitus’ pharmacy contract agreements. The PRA is responsible for the process of pharmacy remittances, including the accuracy of data in pharmacy electronic payments (EFT) and/or 835-remittance advice and the oversight of recoveries of funds from pharmacies. The PRA is responsible for recuperation of monies from pharmacy providers in negative balance status, as well as developing and providing reports to Navitus associates of all reimbursement, recovery, and remittance activities. Day-to-day activities include submitting service requests for any necessary network updates, auditing networks for price change accuracy, monitoring compliance with Navitus pharmacy provider contracts, setting up electronic payments and remits, and responding to questions related to payment issues. The individual in this position is expected to make independent assessments to confirm Navitus is conforming to contractual reimbursement obligations contained in pharmacy agreements.

Requirements

• Associate Degree preferred or equivalent experience
• CPhT preferred
• PBM or managed care is preferred, but not required
• Previous testing experience is preferred
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

Responsibilities

• Administers technical processes in support of system price setups, electronic funds transfer and remittance setups according to policy
• Ensures appropriate controls and oversight reporting on the end-to-end process. If process controls are absent, the expectation is to identify, define, and implement new ones as needed
• Make decisions regarding the resolution of pharmacy network pricing setup issues. Research pricing inquiries from pharmacies and internal teams
• Develop processes to import and export data from Navitus systems, including the Pharmacy Credential and Contracting database and NCRx
• Responsible for pharmacy network rate testing, analysis and impact assessment
• Perform quality assurance to ensure accuracy in pharmacy network rates on an ongoing basis to mitigate the risk of incorrect claims adjudication
• Appropriately identify and escalate improper payments and 835 issues
• Maintenance of department detail work instructions and policies
• Monitoring and reporting of non-compliance relating to overpayments, transaction standard issues and financial regulations
• Provide offset detail to pharmacies impacted in a recovery project prior to receipt of payment and remit
• Responsible for oversight of applicable financial and metric’s reporting, data dictionaries, inquiries, and audits
• Other duties as assigned

Benefits

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees