Representative, PFM Business Intelligence

Inmar Intelligence•Winston-Salem, NC

2d•Onsite

About The Position

Under the direction of a Supervisor, the Representative in PFM Business Intelligence is a member of the Business Intelligence team and is responsible for auditing contract and MAC exceptions and supporting client initiatives. Duties include identifying MAC, pricing and contract exceptions, submitting appeals to the carriers, recording responses from the carriers, preparing standard reporting, interacting with numerous internal and external parties, cross-training with other team members, pulling data and adding MAC appeals information for QBRs and MBRs, product testing and uploading claims and tagging in the Audit Management Application.

Requirements

At least 2 years of relevant experience involving customer service, computer usage, data entry and data analysis AND an Associate’s degree in Business Administration, Accounting, or a related field; OR an equivalent combination of training and experience required to complete the essential functions/job responsibilities of the position.
Proficient in Microsoft Office Suite, Microsoft Windows.
Competent in 10 Key Manual Entry, Google Office Suite.
Adaptable: Responds to change with a willingness to learn new ways to accomplish work.
Teamwork: Builds relationships and works cooperatively with others, inside and outside the organization, to accomplish objectives to build and maintain mutually beneficial partnerships, leverage information and achieve results.
Analytical and Critical Thinking: Ability to tackle a problem by using a logical, systematic, sequential approach.
Communication: Giving and receiving messages and information in written, oral, and visual formats in a clear and concise way for a complete understanding of the meaning and intent.
Curious: A desire to inquire and learn, to seek new knowledge and wisdom, and to listen to the contributions of others with a genuine interest to better self, the team, and the organization.
Problem Solving: Gathers and analyzes information to generate and evaluate solutions to problems, issues and challenges while weighing the accuracy and relevance of the facts, data and information.
Collaboration: Works collaboratively with others to achieve group goals and objectives.
Regularly required to use hands to finger, handle or feel objects, tools or controls, and reach with hands or arms.
Regularly required to talk or hear and read instructions on a computer monitor and/or printed on paper.
Occasionally required to stand, kneel or stoop, and lift and/or move up to ## pounds.
Regularly required to view items at an extremely close range and must be able to adjust and readjust focus.
Candidates must have authorization to work in the U.S. without the need for employer sponsorship now or in the future.

Nice To Haves

Occasionally: Job requires this activity up to 33% of the time
Frequently: Job requires this activity between 33% - 66% of the time
Regularly: Job requires this activity more than 66% of the time

Responsibilities

Identify MAC, pricing and contract exceptions.
Submit appeals to the carriers.
Record responses from the carriers.
Prepare standard reporting.
Interact with numerous internal and external parties.
Cross-train with other team members.
Pull data and add MAC appeals information for QBRs and MBRs.
Perform product testing.
Upload claims and tag in the Audit Management Application.
Understand the nature of retail pharmacy.
Monitor the data to ensure that the carriers adjusted reimbursement.
Run reports and create uploads to vet and submit claims for MAC appeals.
Create and deliver standard MAC reporting on a weekly basis to the client.
Use data visualizations appropriately and effectively.
Identify, develop and implement new procedures to increase efficiency and productivity of work processes.
Participate in product grooming, perform and lead user acceptance testing.
Produce reports and other requested deliverables including financial analysis.
Design internal and external facing dashboards for trending and benchmarking.
Contact clients for invoices when needed; fax invoices and supporting documentation to the carriers.
Upload claims in the Audit Management App.
Tag claims for Audits in the Pharmacy Management tool.
Pursue MAC appeals and Contract exceptions using the Contract Management App and Business Intelligence tools.
Follow documented best practices for submitting MAC and Contract exceptions to the carriers.
Participate in agile missions to improve processes.
Support the Product teams in relation to product enhancements: Identifying product enhancements that would be beneficial for clients.
Performing user acceptance testing on product enhancements.
Pull data for Quarterly Business Reviews and Monthly Business Reviews.
Pull data for ad hoc analysis.
Record the responses from the carriers, potential savings and cost adjustments in the application.
Keep abreast of state level MAC legislation.
Follow up with the carriers after submitting appeals in a timely manner.
Continue to update MAC Appeals forms, spreadsheets, procedures, etc in the MAC Google Drive site.
Share MAC results with the team.
Maintain HIPAA (Health Insurance Portability and Accountability Act) compliance in all client communication.
Perform special projects and other duties as assigned by management.
Support a safe work environment by following safety rules and regulations and reporting all safety hazards.
Put clients first and consistently display a positive attitude and behaviors that demonstrate an awareness and willingness to listen and respond to clients in order to meet their short-term and long-term needs, requirements and exceed their expectations.
Treat clients and teammates with courtesy, consideration and tact; you also have the ability to perceive the needs of internal and external clients and communicate effectively with the objective of delighting and retaining the client.
Build collaborative relationships and work cooperatively with others, inside and outside the organization, to accomplish objectives, develop and maintain mutually beneficial partnerships, leverage information and achieve results.
Set and attain achievable, yet aggressive, goals with a sense of urgency and accountability.
Understand that results are important and focus on turning mission into action to achieve results following the principles of Flawless Execution while consistently complying with quality, service and productivity standards to meet deadlines and exceed expectations by giving our clients the best possible outcomes.