Pharmacy Benefit Config Coordinator

Moda Health•Portland, OR

1d•Hybrid

About The Position

Assists the department lead with various aspects of benefits configuration; and, claims analysis, auditing, processing, and review. Oversee assigned functions’ workflow, maintaining and providing appropriate metrics for process improvements. Work mainly involves the gathering and interpretation of data dealing with problems and difficult situations. This position works under direction, wherein the employee receives general and specific instructions as warranted regarding the scope and approach to projects or assignments.

Requirements

Must have at least an AA degree from an accredited college. Four years of qualifying experience may substitute for the education requirement.
Combined two years of technical or professional experience in claims processing administration preferred.
CPhT preferred.
Position requires complex analysis, a high degree of accuracy, superior organizational abilities, and an ability for focused and thorough research.
Must possess a working knowledge of PBM operations and/or pharmacy benefits related field.
Familiarity with, capacity for use of, terminology as it relates to pharmacy benefits management required.
Ability to read, analyze, and interpret various policies, technical publications, and government regulations: position requires complex analysis and a high degree of accuracy, as well as ability for focused and thorough research.
Ability to gain thorough knowledge and understanding of ODS contracts, group application, and administrative policies affecting benefits configuration.
Ability to ensure conversion of written contracts to coded benefits.
Ability to evaluate and analyze department benefit coding strategies based on state filings and new administrative guidelines.
Ability to perform intermediate mathematical calculations, including ratios and percentages.
Ability to learn and articulate departmental operating policies and procedures; systems and methods; and, tasks.
Demonstrated organizational and analytic skills in identifying benefit configuration and claims administration needs and implementing an effective course of action.
Must be able to prioritize and deal with conflicting workload requirements: good problem solving, decision making, and memory retention skills are required.
Remain aware of any state and/or federal laws and limitations essential to claim processing.
Demonstrated computer skills including Microsoft Office products (intermediate to advanced knowledge with Word and Excel).
Must possess a working knowledge of database relationships.
Abilities to anticipate needs; consistently ensure quality and production standards; maintain a high level of confidentiality; project a professional business image; be flexible and adapt to change; handle stress and pressure; and, multi-task.
Training level proficiency in ODS internal and external PBM claims processing systems will be required.
Typing proficiency of 25 wpm on a computer keyboard.
Excellent verbal, written and interpersonal communication skills in personal and small group meetings.
Ability to speak and write clearly, and communicate messages to appropriate individuals, and organize information clearly and precisely.
Must have ability to work well with Commercial, Medicare and Medicaid populations and to resolve pharmacy conflicts in a professional manner.
Use general methods of tactful public communication.
Ability to work independently with little supervision.
Ability to come to work on time and daily.
Ability to explain information to others and work well with others.

Nice To Haves

Four years of qualifying experience may substitute for the education requirement.
Combined two years of technical or professional experience in claims processing administration preferred.
CPhT preferred.

Responsibilities

Responsible for coding new plans and changes into the third-party PBM database and internal claims adjudication system: ensuring the performance of post implementation audits to ensure customer billing, pharmacy payment, and benefit structure are consistent with contract terms.
Oversee the renewal process of existing groups; coordinate the coding of all new, unique group benefits to help ensure that corporate standards and turnaround times are met.
Assist in correcting eligibility errors in the third-party PBM database.
Perform ongoing coding maintenance and make additions/changes in a timely and accurate manner.
Audit new and existing plan designs by running and analyzing QC reports.
Coordinate plan changes and updates with internal and external personnel as necessary.
Ensure the accurate maintenance of the systems utilized by the Customer Service Team when quoting benefits.
Establish and maintain test claims for new plans.
Perform formulary updates to the various formularies as new and updated drugs are released, as per direction from clinical staff.
Compare data on claim form(s) with plan document and other company records to ascertain completeness and validity of claim.
Review claim information to ensure accuracy, completeness, and determine qualifications for benefits under a particular benefit plan.
Correspond with clients and claimants to correct claim forms as necessary and investigate questionable entries.
Send custom and routine form letters as necessary, and update member files with pertinent information.
Work with proper internal and external partners to adjust COB claims, or process COB files to ensure proper reimbursement to primary and/or secondary payors.
Process voids, refunds, and adjustments.
Perform manual calculation of benefits to enter correct information on claims that the system cannot automatically process.
Maintain current understanding of the claims processing system, imaging system, claims processing policies & procedures, and unique benefits/processing rules for self-funded plans.
Understand, analyze, and be capable of adjusting Part D claims, including TrOOP, cost-sharing, low-income subsidy, Part D True Up, and claim processing error and coordination of benefit (COB) adjustments.
Maintain both electronic and paper reference materials, claims records, and files as required.
Complete filing, photocopying, faxing and other administrative functions as needed.
Be an active team player, responding to the needs of the unit as they arise.
Perform other duties as assigned.