Location Type: Remote Additional Location: AL; AZ; AR; CA; CO; DE; DC; FL; GA; HI; ID; IL; IN; KS; KY; LA; ME; MD; MA; MI; MS; MO; NV; NH; NJ; NY; NC; ND; OH; OK; OR; RI; SD; TN; TX; UT; VT; WA; Puerto Rico; Schedule: Full_time Req: R-277857
Description
The Pharmacy Claims Representative 2 adjudicates pharmacy claims and process pharmacy claims for payment. The Pharmacy Claims Representative 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.
ResponsibilitiesThis position is for Enclara Pharmacia, a Humana company. Enclara, is a wholly owned hospice and palliative care pharmacy business acquired by Humana in 2021. Enclara is the nation’s largest full-service pharmacy benefits manager (PBM) specifically for the hospice and palliative care sectors. Serving over 450 customers and nearly 100,000 patients nationally, Enclara works closely with hospices to reduce pharmacy costs, improve patient care and support caregivers through: digital innovations, flexible medication access, one-on-one clinical support, and excellent customer service.Schedule: Monday through Friday 2:30PM to 11:00PM ET, with every 4th weekend rotation (Sat & Sun – off by 8 PM ET)
Location: Remote USA – Pharmacy Technician license is required if the BOP requires licensing for techs in your state.
Essential Duties and Responsibilities:
- Assist in setting up and maintaining hospice/facility/pharmacy relationships under the direction of the Pharmacy Claims Team Leaders & the Pharmacy Claims (Support Services) Manager
- Assist pharmacies with claims adjudication
- Complete incoming tasks as assigned by the Pharmacy Claims Team Leaders and the Pharmacy Claims (Support Services) Manager
- Obtain all necessary information for facilities and their related pharmacies
- Assist the Call Center management team with projects to enhance the workflow and success of the Call Center
- Assist Customer Service team with claims research/resolution
RESPONSIBILITIES (include but are not limited to):
Billing:
- Assist pharmacies with claims adjudication by adjusting/correcting authorizations in dispensing systems and PBM systems
- Ensure timely adjudication of prescription claims through PBM systems
- Contact hospices for authorizations/approvals for submitted claims where necessary
- Ensure accuracy of patient profile data including related/not related status, authorization status, etc
- Research and correct pharmacy invoices from hospices
Required Qualifications
- Less than 2 years of technical experience
- Less than 5 years of data analysis & problem solving skills
- Comprehensive knowledge of all Microsoft Office applications, including Access, Word, Excel and PowerPoint
- Strong verbal and written communication skills, including the ability to tailor communication to audience
- Strong organizational and time management skills
- Ability to handle multiple tasks, meet deadlines, and follow-up timely
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
- High School Diploma or GED
- Previous experience with pharmacy benefits management
- Claims experience
- Knowledge/experience working with SQL (via MS SQL Server, Oracle, PL/SQL or other)
- Pharmacy Tech experience
Work-At-Home Requirements
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Additional Information
COVID 19 Vaccination:
For this job, associates are required to be fully COVID vaccinated (preferred) or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
If progressed to offer, you will be required to:
Provide proof of full vaccination or commit to testing protocols OR  Â
Provide proof of applicable exemption including any required supporting documentationÂ
​​Medical, religious, state and remote-only work exemptions are available.