Encounter Technical Data Specialist

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make. Job Posting Title Encounter Technical Data Specialist Job Description Summary Conducts data validation studies and responds to technical inquiries received from the Medicaid Managed Care Organzations (MCOs) contracted with a state program. Coordinates the receipt and adjudication of the pharmacy data that is required to be sent from the MCOs to the State's PBM (pharmacy benefit manager). Responds to technical and claims inquiries from the MCOs entailing the review of pharmacy encounter records that were not accepted at either the FTP gateway or POS system requiring further research in the pharmacy adjudication system and research in the applicable FTP files and servers. Determines where the file is failing in certain circumstances and also defines the error codes associated with potential claim issues. Also tests new files in concert with the MCO. Job Description Thoroughly and accurately researches, reports on and documents encounter claims that were processed by the MCO and submitted to the company. Conducts data validation studies to review pharmacy encounter records to validate encountered and billed for financial reimbursements by MCOs are timely, accurate and complete. The data validation study is also a routine method of review that assists the company in deterring, detecting and/or recovering inappropriate pharmacy benefit payments due to billing inaccuracies, claims processing and/or abusive and fraudulent practices. Ensures recovery of inappropriate payments of Federal, State and company health benefits to Providers and Consumers. Analyzes and reports data validation study findings by generating, tracking and following-up on corrective action letters. Conducts re-audits of MCOs to verify corrective actions were fully implemented and ensures correct processes going forward. Works with internal teams to set up and test new MCOs' claim submissions. Provides technical assistance to Providers' Clinical, Claims and Financial staff regarding CMS, FTP, POS system and State and Federal guidelines for proper medical records coding and billing practices. Serves as a medical records coding expert and advises Providers of Federal and State guidelines for proper procedure, revenue, and diagnostic coding. Develops and maintains working relationships with PNOs and Clinic employees, and all internal department employees to help facilitate full implementation. Responsibilities 2 years of claims and encounter transaction research experience at expert level. Familiar with current NCPDP D.0 Transaction Standards. Ability to deal with many functional areas of a national organization. Excellent verbal and written communication skills. Excellent research and analytical skills. Ability to identify encounter/claims processing and policy issues as they apply to corporate and contract policies. Strong spreadsheet and word processing skills. Work Experience Work Experience - Required: Claims Work Experience - Preferred: Education Education - Required: Education - Preferred: Associates - Business Administration, Associates - Computer and Information Science Certifications Certifications - Required: Certifications - Preferred: CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy - Pharmacy To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail. Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, genetic information, marital status, family status, national origin, age, disability, veteran status, or any other legally protected class under federal, state, or local law. Prime Therapeutics' fast-paced and dynamic work environment is ideal for proactively addressing the constant changes in today's health care industry. Our employees are involved, empowered, and rewarded for their achievements. We value new ideas and work collaboratively to provide the highest quality of care and service to our members. If you are looking to advance your career within a growing, team-oriented, award-winning company, apply to Prime Therapeutics today and start making a difference in people's lives. Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. If you are an applicant with a disability and need a reasonable accommodation for any part of the employment process, please contact Human Resources at 1.866.469.1257 or email Careers@primetherapeutics.com.