Pharmacy/Billing Technician
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Job Description
Pharmacy Technician managing claims adjudication, billing, and prior authorizations for American Health Plans’ Medicare Advantage I-SNP. Ensuring compliant medication access and pharmacy operations.
Responsibilities:
- Review daily point-of-service pharmacy claims, resolve actionable items, track activity, and provide reporting
- Investigate and resolve pharmacy claim rejections, reversals, and payment discrepancies in real time
- Collaborate with external pharmacy and claims teams to ensure accurate claim adjudication and payment
- Submit and track claim overrides in compliance with plan and CMS guidelines
- Ensure proper coordination of benefits, hospice billing considerations, and Part A/B versus Part D determinations
- Facilitate prior authorization processes with prescribers, pharmacies, and internal clinical staff
- Gather and submit documentation for prior authorization review; monitor status and communicate determinations
- Serve as primary billing and claims contact for contracted network and long-term care pharmacies
- Educate pharmacies and provider offices on billing requirements, formulary limitations, and plan processes
- Support transitions of care by ensuring medication access and clean claim processing
- Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies
- Document claim interventions, communications, and resolutions in the plan’s system
- Assist with internal audits, reporting, and quality improvement initiatives
- Identify claim rejection and prior authorization delay trends and escalate systemic issues to leadership
- Monitor daily billing and claims work queues and meet productivity and turnaround time expectations
- Participate in cross-functional meetings with pharmacy operations, clinical, and provider relations teams
- Support process improvement initiatives that enhance claims efficiency and member medication access
- Liaise with the Enrollment Department regarding member eligibility processing
- Recognize formulary requirements including prior authorization, Step Therapy, Quantity Limits, and NCPDP reject codes
- Coordinate clinical reporting
- Follow up on and resolve open items in a timely manner
- Participate in special projects and business initiatives
- Perform other duties as assigned
Requirements:
- High school diploma or equivalent
- Minimum of 2 years as a Pharmacy Technician, in long-term care, or health plan experience
- Experience working pharmacy claims, rejections, and prior authorizations (PAs)
- Experience in planning and implementation
- Proficiency with Microsoft Suite applications
- Ability to navigate multiple systems
- Strong analytical skills
- Proficient communication and presentation skills
- Adherence to Centers for Medicare and Medicaid Services (CMS) regulations and compliance requirements
- Successful completion of required training
- Pharmacy Technician certification preferred
Benefits:
- Reasonable accommodation for applicants with disabilities
- Full-time remote work arrangement
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