Pharmacy Analyst - Provider Services & Claims Administration

Alberta Blue Cross; Edmonton; Hybrid; CAD 42,000 - 68,000; Full time

Job summary

Alberta Blue Cross® in Edmonton is seeking an enthusiastic individual to join our Provider Services & Claims Administration team, handling manual pharmacy claims and complex inquiries with accuracy and timeliness.

Under supervision, you will perform QA on adjudication results, assist providers with submissions/reversals, and participate in system testing and reporting while maintaining superior customer service.

Qualifications

• Strong customer service orientation and ability to build effective relationships with stakeholders.
• Excellent problem-solving abilities and high attention to detail.
• Excellent organizational and time management skills with the ability to prioritize tasks.
• Adaptability and willingness to adjust to changing priorities.
• Ability to work with minimal supervision and accountability.

Responsibilities

• Process manual pharmacy claims, including high-cost drug claims, ensuring adjudication accuracy and timeliness.
• Perform quality assurance checks on claim adjudication results and complete necessary adjustments.
• Educate and assist pharmacy providers with claims submissions and reversals, including collection of monies.
• Conduct system testing and track reporting on work initiatives.
• Research and analyze information to resolve complex inquiries or unique situations.
• Monitor production and ensure timelines and output meet expectations.
• Suggest workflow improvements to increase efficiency and innovation.
• Be available for occasional flexible hours.

Job description

Alberta Blue Cross® is an Alberta based organization dedicated to delivering exceptional customer experience and community leadership. We’re committed to providing the best health coverage to over 1.8 million members and take an active role in promoting wellness. We believe in what we do—and place trust in our employees to deliver our vision.

Working at Alberta Blue Cross® means having a career where you’ll be recognized for your contributions. We value diversity, encourage our team members to maintain a healthy work-life balance and provide opportunities for career growth.

OVERVIEW:

Alberta Blue Cross® is currently seeking an enthusiastic individual to join our Provider Services & Claims Administration team working in a flexible work style arrangement. With the support of the Team Manager, and under the guidance of a Team Lead, this position is responsible for day-to-day activities related to processing manual pharmacy claims, managing complex pharmacy drug claim inquires, and adjusting direct bill drug claims. This is a detailed position, requiring accuracy and efficiency, to ensure that work objectives and timelines are met, and our reputation for excellent customer service is maintained.

WHAT YOU WILL DO:

• Process manual pharmacy claims, including high-cost drug claims, ensuring claims are adjudicated accurately in accordance with drug benefit plan coverage, and in a timely manner.
• Perform quality assurance checks on claim adjudication results, and complete claim adjustments when necessary.
• Assist and educate pharmacy providers with claims submissions and reversals, including collection of monies from pharmacy providers.
• Perform system testing.
• Research and analyze information to resolve complex inquiries or unique situations.
• Track and complete reporting on work initiatives.
• Monitor individual production to ensure acceptable quantity of output and timelines are met.
• Make suggestions to improve workflows, increase efficiency, and be innovative.
• Be willing to occasionally work flexible hours.

WHAT YOU WILL HAVE:

• Demonstrated commitment in delivering superior customer service, including establishing and maintaining effective working relationships with internal and external stakeholders.
• Strong problem-solving abilities and attention to detail are critical, demonstrating the ability to use good judgment in evaluating and decision-making, and completing work with a high degree of accuracy.
• Excellent organizational and time management skills with the ability to prioritize tasks, manage a heavy workload, and meet tight timelines.
• Demonstrated willingness and ability to adapt to changing priorities and processes.
• Demonstrated ability to work with minimal supervision, with a strong sense of accountability, in a flexible work style arrangement.
• Computer proficiency with Microsoft Word, Excel, and Outlook is essential. Exposure to Access would be beneficial.
• Knowledge of the pharmacy industry, including drug plan design and claim adjudication standards, is an asset.

This position will remain open until a suitable candidate is selected.

Alberta Blue Cross® is an inclusive employer committed to a workplace that reflects the diversity of the communities we serve. We empower and are advocates for our team members by welcoming, respecting and valuing their unique perspectives, backgrounds, and experiences.

We offer the opportunity to work in an innovative, high-energy team-focused environment.

A criminal record check satisfactory to Alberta Blue Cross will be required as a condition of employment, following a conditional offer.