Pharmacy Claims Representative II

Must be able to work: Monday - Friday, 2:30pm to 11pm EST plus every fourth weekend 

Essential Functions
Note: The essential duties and primary accountabilities below are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Incumbents may perform all or most of the primary accountabilities listed below. Specific tasks, responsibilities or competencies may be documented in the incumbent’s performance objectives as outlined by the incumbent’s immediate supervisor or manager.
1. Assist pharmacies with real-time and retrospective claims adjudication. Adjust and correct authorizations in dispensing and PBM systems to ensure timely claims submission. Research and resolve rejected claims by contacting hospices for approvals or updated authorizations.
2. Maintain accuracy of patient profiles, involving authorization status and relatedness indicators.
3. Evaluate and process compound medication claims, ensuring accuracy in ingredients, quantities, and pricing.
4. Research pharmacy invoices and hospice billing issues, reconciling discrepancies as needed.
5. Collaborate with the Customer Service team on complex claims research and resolution.
6. Understand Enclara Pharmacia’s standard and custom formularies and differentiate between Per Diem (PD) and Fee-for-Service (FFS) billing models across hospice partners.
7. Contact facilities and pharmacies to verify and collect necessary information for onboarding spreadsheets. Coordinate PBM and billing system verification with facility pharmacies. Maintain and update facility-pharmacy tracking spreadsheets and communicate status with implementation teams.
8. Educate facility pharmacies on billing procedures and contacts for rejected claims.
9. Collect and verify missing or incomplete facility information reported by the Call Center team. Ensure all facilities are correctly linked to their respective hospices in internal systems. Assist with Confirmation Fax reports to validate and update facility-pharmacy relationships and demographics.
10. Complete tasks and special projects assigned by Pharmacy Claims Team Leaders on Pharmacy Claims (Support Services) Manager.
11. Support Call Center leadership in initiatives to streamline processes and improve service outcomes.
Marginal or Additional Functions

1. Performs other duties as assigned or apparent.
Supervisory and Managerial Responsibility

• Supervisory/managerial responsibility is not applicable

Knowledge, Skills & Abilities

• Education, Licensure or Certification:
  • High school diploma or equivalent required
  • CPhT or EXCPT preferred 
  Work Experience or Related Experience:
  • Minimum of six (6) months of pharmacy technician experience.
  • Experience with pharmacy claims adjudication is required.

Specialized Knowledge, Skills & Abilities:
• PBM or billing platform experience preferred
• Proficient in Microsoft Office Suite, especially Excel, Word, Outlook, and Access
• Comfortable navigating multiple software systems, including pharmacy dispensing and PBM platforms
• Excellent verbal and written communication skills
• Ability to learn proprietary systems used for claims management and facility tracking.

Equipment
• Working knowledge of a PC, business and communications software (MS Office) and web-based tools are required

Travel Requirements and Conditions

• Travel is not required
Work Environment, Conditions and Demands

• Work is generally performed in a climate-controlled, smoke-free office environment.
Physical Requirements and Demands

• May sit, stand, walk, stoop, or bend intermittently throughout the day.
• May be required to sit for extended periods (7-10 hours/day).
• Occasional lifting of up to 25 pounds may be required.
• Requires manual dexterity to operate office equipment.
• Visual acuity to read fine print and digital screens; must be able to hear and respond to verbal communication.
Additional Position Information

• No additional information is applicable

Qualifications Education Required High School or better. Experience Required Experience with pharmacy claims adjudication is required. Preferred Minimum of six (6) months of pharmacy technician experience. Equal Opportunity Employer
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