Experience with payer denials and claim exceptions
This role optimizes the payment cycle for retail and specialty pharmacy claims by ensuring accurate workflow and aligning collections with contracts
Job Summary
This role optimizes the payment cycle for retail and specialty pharmacy claims by ensuring accurate workflow and aligning collections with contracts.
The specialist is responsible for securing third-party payments, maintaining secondary billing processes, and responding to audit requests from commercial health plans.
Candidates must possess advanced knowledge of state, federal, and PBM accreditation rules regarding pharmacy benefit and medical benefit claims billing.
Matching Summary
This role optimizes the payment cycle for retail and specialty pharmacy claims by ensuring accurate workflow and aligning collections with contracts.
Skills & Requirements
Must-have
Advanced knowledge of PBM rules and regulations
Strong proficiency in Microsoft Excel and Teams
Experience with payer denials and claim exceptions
Nice-to-have
Proactive communication with finance staff
Ability to identify process improvement trends
Experience defending audit requests from payors
Key Requirements
Bachelor's degree or 2 years relevant experience
Registered technician with Ohio Board of Pharmacy
Active PTCB or NHA certification required
Maintain ongoing PTCB certification and registration