Pharmacy Claims Audit Supervisor - Remote US

Summary

Your role in our mission

Essential Job Functions

• Supervises claims program administration to ensure proper claims practices and procedures.
• Supervises billing, claims and associated administrative activities to ensure compliance with laws, regulations, policies, agreements and contractual arrangements.
• Assists in implementing procedures to adjust claims when original demographic, sponsor or charge information is in error; monitors and controls resubmission of denials, rejections and appeals.
• Intercedes with third parties in unusual situations involving payment or adjustment of charges on accounts; consults with departments concerning services which affect collection of charges.
• Assists examiners in investigating claims and assists and/or performs settlement negotiations. Supervises claim settlement processing.
• Assumes supervisory responsibility for electronic and paper claims submissions; oversees analysis, correction and resubmission of registration and eligibility of edits and errors.
• Recommends and/or initiates the selection and hiring of employees. Trains and evaluates employees to enhance their performance, development, and work product. Addresses performance issues and makes recommendations for personnel actions. Makes recommendations for salary increases, transfers and terminations to manager.
• Researches coding and reimbursement requirements for compliance with local, state and federal regulations.

Basic Qualifications

• Bachelor's degree or equivalent combination of education and experience
• Bachelor's degree in business administration, insurance or related field preferred
• Six or more years of claims experience
• Two or more years of leadership experience
• Experience working with proper claims handling, policies and procedures
• Experience working with computer based analysis tools
• Experience working with insurance and/or medical terminology

Other Qualifications

• Organizational skills to balance and prioritize work
• Analytical and problem solving skills
• Communication skills
• Human relations skills to select, develop, mentor, discipline and reward employees
• Negotiation skills to interact with claimant
• Ability to understand and convey applicable laws, regulations and practices regarding the insurance industry
• Ability to work independently and lead group activities

Work Environment

• Office environment

What we're looking for

What you should expect in this role