Senior Transition Pharmacy Claims Professional
This job is no longer available
There are still lots of open positions. Let's find the one that's right for you.
About The Position
The Senior Pharmacy Claims Professional plays a crucial role in the adjudication of pharmacy claims and the processing of these claims for payment. This position involves handling moderately complex to complex issues, requiring a thorough analysis of various factors and data. The Senior Pharmacy Claims Professional is responsible for overseeing processes to ensure accuracy in pharmacy point of sale transition adjudicated claims. This role demands a deep understanding of pharmacy claims processing and the ability to evaluate situations critically to ensure compliance with both state and federal regulations. In this position, the Senior Pharmacy Claims Professional will analyze, monitor, and enhance processes related to claims adjudication logic specifically for pharmacy transition point of sale claims. Collaboration is key, as this role involves working closely with cross-functional project teams and both internal and external partners to identify impacts, ensure project requirements are met, and test projects from start to finish. The Senior Pharmacy Claims Professional will also be responsible for documenting processes, reviewing them for compliance, and monitoring them regularly to ensure they meet the necessary standards. This position offers the opportunity to influence departmental strategy and make decisions on complex issues regarding the technical approach for project components, thereby gaining a broad base of claims knowledge. Additionally, the Senior Pharmacy Claims Professional will serve as a subject matter expert for pharmacy transition processes and claims processing logic. This includes acting as a speaker during CMS Program audits and compliance mock audits, ensuring adherence to all federal and state requirements, and creating, updating, and maintaining various reports and policy/procedure documents. The role may also involve leading projects related to required process or logic changes, along with other duties as assigned.
