Pharmacy Claims Specialist (Full Time)

Job Description

POSITION SUMMARY: Remote position.

The essential purpose and function of this position is to support Pharmacy Services leadership in the management, review, audit and reconciliation of daily, weekly, and monthly third party medication claims to ensure that the appropriate information is obtained and action has been taken to resolve payment. Involvement of center and pharmacy staff as well as personnel at third party payer organizations will be essential to the success of this position. As the Pharmacy Claims Specialist and in collaboration with Genesis corporate, operations and clinical staff, this position is required to develop, communicate to various audiences throughout the company, and implement the necessary processes to minimize the impact of non-covered medication costs incurred by the centers in the company. Adherence to and compliance with specified timelines and deadlines is essential for success in this position. This position will have a significant impact on a $6 million spend category and is integral in reducing the expense to ensure it is minimized.


Reliability, accessibility, attention to detail, critical analysis/problem solving and timely response to requests for information and/or action are essential to success in this position.


An essential function of this position will be the successful audit of pharmacy claims, research and action related to denied, pended and other unpaid claims and subsequent recovery of revenues related to those claims.



Claims Auditing and Recovery

  1. View rejected medication claims from various sources and file the necessary information for payment with the third party plan online, by phone or via facsimile depending on plan requirements.

  2. Retrieve all necessary information from various sources required to complete the requested elements for payment by the third party plan. This may include direct contact with the center based staff, direct contact with the servicing pharmacy or use of various online sources.

  3. Verification of patient/resident coverage for benefits.

  4. Act as a liaison between the third party payer, servicing pharmacy and nursing center.

  5. Provide information to centers regarding alternatives covered by the third party payer.

  6. Provide reports that demonstrate effectiveness of position related to attempted claims recovery volume, efficiency of those attempts, and financial benefit to center and company as result of those efforts on a weekly, monthly, quarterly basis as needed.

  7. Monitor and address questions/irregularities with third party claims that will be billed to individual facilities.

  8. Ability to monitor patient/resident census information to ensure that it is complete and correct for the pharmacy to utilize for billing purposes.

  9. Identifies/documents procedures, performs, trains personnel, troubleshoots and makes/recommends improvements to claims processes from initiation through reconciliation

  10. Prioritize daily, weekly and monthly objectives based on need, communication with supervisor, and make necessary adjustments for urgent/time sensitive issues.

Compliance Responsibilities

  1. Complies with applicable legal requirements, standards, policies and procedures including but not limited to those within the Compliance Process, Standard/Code of Conduct, Federal False Claims Act and HIPAA.

  2. Participates in required orientation and training programs.

  3. Promptly reports concerns and suspected incidences of non-compliance to supervisor, Compliance Liaison or to the Compliance Officer via the Integrity Hotline.

  4. Cooperates with monitoring and audit functions and investigations.

Participates, as requested, in quality assurance and process improvement activities.





SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS: 1. Ability to work across clinical/billing platforms. 2. Working knowledge of reimbursement in a Long Term Care setting, experience with pharmacy claims processing is highly preferred. 3. Working knowledge and ability to develop expert-level comprehension of Medicare Part D (including eligibility, LIS, dual eligibility, transition plans, etc.), and Medicaid billing and eligibility requirements. 4. Excellent verbal and telephone communication skills. 5. Ability to accurately and appropriately document processes, steps and results. 6. Ability to be accessible and responsive to stakeholders from a variety of time zones and locations throughout the United States. 7. Analytical thinking, structured problem-solving skills. 8. Ability to work independently with minimum supervision. 9. Experienced user of MS & Google platforms. 10. Ability to access and utilize available online resources from the Internet as well as company supported information platforms.

Position Type: Full Time
Req ID: 339088
Center Name: Genesis HealthCare