Job title: Pharm Operations Encounters & Eligibility Analyst
Company: Horizon Blue Cross Blue Shield of New Jersey
Job description: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Job Summary: This position is accountable for managing Horizon NJ Health’s pharmacy accounts receivable, including HIV and Hemophilia reimbursement due from the state of New Jersey. Responsible for conducting research and root cause analysis of all encounter denials, rejections and aging claims. Position will also be responsible for correcting errors and identification and implementation of new processes and solutions to alleviate recurrences. In addition, this position is responsible for reconciliation of all daily and monthly eligibility loads to multiple pharmacy applications and performs both primary and secondary research of TPL claims. The position will also be responsible for data entry and processing of all pharmacy lock-in information, all Novologix clinical drug protocols and maintenance and coordination of all J-code file submissions to TPA.
- Reconciliation of pharmacy HIV and Hemophilia encounters to General Ledger balance and coordination with finance.
- Design, customize and generate ad hoc reports for analysis of members for inclusion on TR65 file based on diagnosis and subsequent reimbursement from state of New Jersey.
- Timely compilation and submission of pharmacy encounter claims to the state of New Jersey
- Timely processing and re-submission of all encounter rejections to reduce prospect of withholds from state
- Research and analysis of all duplicates on encounter file. Must keep duplicate rate to minimum to reduce prospect of withhold from state
- Full reconciliation of all daily and monthly eligibility loads
- Responsibility for reconciling all eligibility discrepancies including that necessary for pharmacy TPL claims processing
- Will be assigned as the ‘go-to’ individual for addressing all internal and external customer pharmacy eligibility and encounter inquiries on a consistent basis
- Process J-code AWP and ASP file for ultimate load by TPA
- Track file for timely loading and review for accuracy. Advise management of discrepancies
- Data Entry of member lock-in information, report and letter generation
- Tracking of all physician lock-in responses.
- Implementation of clinical protocols as designed and tested into Automated Prior Authorization system
- Performs other duties as assigned by management
Core Individual Contributor Competencies
- Customer Focus
- Accountable
- Learn
- Communicate
Education/Experience:
- Prefers a Bachelor’s Degree in Business Administration, Health Administration, Accounting or other related degree
- Internal applicants lacking a degree but who have related business experience and who have demonstrated performance above the contributor level will be considered
- Require one to three years experience in accounting, claims payment, member eligibility research or encounter processing
- Requires a minimum of two years experience in pharmacy benefit management prescription program with claim adjudication experience
- Prefer a minimum of three years experience as a pharmacy technician and/or pharmacy account manager
Additional licensing, certifications, registrations:
- National Pharmacy Certification required or must be maintained within 6 months of hire date.
Knowledge:
- Requires knowledge of Accounts Receivable, Accounts Payable and General Ledger Balance
- Requires strong knowledge of Pharmacy claims processing data elements such as National Drug Code (NDC)
- Requires strong knowledge of National Council Prescription Drug rogram standards and claims processing protocols
- Prefer Knowledge of Horizon NJ Health member enrollment
- Requires knowledge of PC’s and applicable software (i.e., spreadsheet and database applications)
- Requires knowledge of research techniques and resources
- Requires working knowledge of Medispan and/or First Data Bank including Therapeutic Drug Class.
Skills and Abilities:
- Must have effective verbal communication skills and demonstrate the ability to work well within a team
- Demonstrated ability to deliver technical information to less technical individuals
- Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development
- Proven time management skills are necessary
- Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required
- Proven ability to exercise sound judgment and strong problem solving skills.
- Proven ability to ask probing questions and obtain thorough and relevant information.
- Needs to demonstrate willingness to cross-train, and be cross-trained, in other roles/duties
- Must be detail oriented with strong organizational and data processing skills.
- Proven ability to follow detailed instructions is essential, along with proven problem solving skills
- Proven analytical, research and problem solving skills a must
- Must demonstrate the ability to learn quickly and apply learning to new situations
- Must exhibit flexibility to change as appropriate
- Must demonstrate the ability to effectively present information and respond to questions from managers, clients and customers
Salary Range: $54,600 – $73,080
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
Expected salary: $54600 – 73080 per year
Location: Hopewell, NJ
Job date: Thu, 29 Feb 2024 05:40:57 GMT
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