Pharmacy Desktop Auditor (Claims Professional 2)

The Humana Pharmacy Solutions traditional Desktop Audit team oversees and manages multiple aspects related to reviewing pharmacy claim submissions for accuracy and appropriateness. Facilitation of discussions with CMS representatives and leaders of other teams is utilized by Desktop Audit team members to continuously improve the audit process in a field of ever evolving standards and regulations. Associates of the Desktop Audit team set the tone and standard for pharmacy claim review. The Pharmacy Claims Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

Scope of Role and Responsibilities:
As a Pharmacy Claims Professional 2 Desktop Auditor you will perform audit functions including review of pharmacy submitted documentation, professional notation of necessary changes and education points, research of new policies and standards, responding to pharmacy inquiries and supporting other audit functions as needed. This role will maintain ownership of key processes.

Responsibilities include:

• 
  Maintain Pharmacy Technician Certification including learning industry changes and completing CE’s required to renew certification.
• Perform specific audit-related functions within the Audit program which can include calling on suspicious claim submissions, performing state specific law research and quality assurance.
• Review prescription documentation provided by pharmacies, perform comparative analysis against claim billing submissions, document and explain any discrepancies or inaccuracies, respond to pharmacy inquiries and facilitate education of adjustments and changes.
• Lead discussions regarding audit outcomes and claim corrections.
• Regularly resolve concerns and challenges presented in an independent manner utilizing tools and resources provided assisting in process improvement and elevation.

Required Qualifications

• Currently Certified Pharmacy Technician (PTCB)
• Excellent organizational and time management skills with attention to detail
• Prior problem solving experience, including root cause analysis and resolution
• Strong written and verbal communication skills
• Prior demonstration of process improvement ideologies and implementations
• Proficiency in Microsoft Office applications, including Word, Excel and Outlook

Preferred Qualifications

• Bachelor’s Degree or equivalent combination of education and experience
• Prior pharmacy claims experience
• Knowledge of Humana Pharmacy claims processing system and processes

Additional Information

• Interview Format
• As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called Modern Hire. Modern Hire Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.
• If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
• Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana’s secure website.

Scheduled Weekly Hours

40