This role optimizes the payment cycle for retail and specialty pharmacy claims by ensuring accurate workflow of pharmacy accounts
Job Summary
This role optimizes the payment cycle for retail and specialty pharmacy claims by ensuring accurate workflow of pharmacy accounts.
The specialist is responsible for defending audit requests from commercial health plans and ensuring the accuracy of claims to retain reimbursement.
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 of pharmacy accounts.
Skills & Requirements
Must-have
Pharmacy Benefit Management rules knowledge
Microsoft Excel and Teams proficiency
Payer remittance reconciliation expertise
Insurance claim denial resolution skills
Secondary billing process management
Nice-to-have
Proactive communication with finance staff
Trend identification for process accuracy
Scalable process improvement contributions
Strong advocacy for efficient claim resolution
Key Requirements
Bachelor's degree in Business or healthcare field
2 to 4 years of relevant experience preferred
Registered technician with State of Ohio Board of Pharmacy
Active PTCB or NHA certification required prior to start
Must maintain ongoing PTCB certification and board registration