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Business      Claim Specialist

Visa                GC/Citizen

Location        255 Technology Park, Lake Mary FL 32746

Division         Pharmaceutical

Pay                $16.00/hr.

Contract        5 Month

Timings        Mon - Fri between 9.00AM – 6.00PM

POSITION OVERVIEW

The primary function/purpose of this job.

Verify member submitted claims forms, member’s eligibility and pharmacy information is complete and accurate, updating system information as needed. Superior data entry proficiency is expected in order to provide accurate and timely processing of claims submitted by member, pharmacy or appropriate agency. Moderate knowledge of drugs and drug terminology used daily. Process claims according to client specific guidelines while identifying claims requiring exception handling. Navigate daily through several platforms to research and accurately finalize claim submissions. Oral or written communication with internal departments, members, pharmacies or agencies to resolve claim issues. Adhere to strict HIPAA regulations especially when communicating to others outside the client. Prioritize and coordinate influx of daily workload for claims processing, returned mail and out-going correspondence and e-mails to assure required turnaround time is met. Assess accuracy of system adjudication and alert management of potential problems affecting the integrity of claim processing. Analyze claims for potential fraud by member or pharmacy. May be required to work on special projects for claims team.

ESSENTIAL FUNCTIONS:

The 6-10 major responsibility areas of the job. Weight: (%)

(Total = 100%)

1. Manage member and client expectations related to claim reimbursements. Input claim requests into adjudication platform maintaining compliance to performance guarantees, HIPAA guidelines and service standards, which include production and accuracy standards. Processing according to client guidelines making exceptions upon member appeal and client approval. Recognize and escalate appropriate system crises/problems and fraudulent claims to management. 40 %

2. Identify claims requiring additional research, navigate through appropriate system platforms to perform research and resolve issue or forward as appropriate 15 %

3. Research to define values for missing information not submitted with claim but required for processing. Identify drug form, type and strength to manually determine correct NDC number value which will allow claim to process. Continue researching values if system editing does not accept original assigned value. Utilize anchor platform, internet resources and/or contacting retail pharmacist as resources for missing values. 15 %

4. Initiate correspondence to members, pharmacies or other internal departments for missing information, claim denials or other claim issues. 15 %

5. Evaluate claim submission, ensure all required information is present and determine what action should be taken. Confirm patient eligibility and verify patient information matches system. Update member’s address to match claim form if necessary. 5 %

6. Identify exception handling and process per client requirements. Monitor system to ensure client specific documentation related to claims processing and benefits is current and system editing is operating appropriately. 5 %

7. Variety of other miscellaneous duties as assigned 5 %

SCOPE OF JOB

Provide quantitative data reflecting the scope and impact of the job – such as budget managed, sales/revenues, profit, clients served, adjusted scripts, etc.

Maintain an average of 30 Commercial claims per hour (cph) or 35 Work Comp claims per hour (cph).

Formal Education and/or Training:

High school diploma or equivalent required, some college or technical training preferred

Years of Experience:

Two years’ experience in P.B.M. environment is helpful but not required.

Computer or Other Skills:

Strong data entry, 10-key skills, general PC skills and MS Office experience

Knowledge and Abilities:

• Strong data entry and 10-key skills

• Retail pharmacy, customer service experience helpful but not required

• PC and MS Office literate

• Strong attention to detail

• Excellent retention and judgment ability

• Proficient written and oral communication skills

• Ability to work in fast-paced, production environment

• Reliable, self-motivated with excellent attendance

• Team player who has the ability to stay on task with little supervision

Thanks & Regards,

Ranadheer Murari | Recruitment Executive | Mindlance, Inc. | W: 678 405 3590

ranadheerm[at]mindlance.com