Administrator, Pharmacy Reimbursement

Navitus Health Solutions, LLC; United States; Remote; USD 49,000 - 58,000; Full time

Benefits offered by this job

Health/Dental/Vision

PTO 20 days

Parental leave 4 weeks

9 paid holidays

401K match 5%

Adoption assistance

Flexible Spending Account

Education & membership

Referral bonus

Job summary

Navitus Health Solutions is seeking a Pharmacy Reimbursement Administrator to join our team. The PRA works with Provider Relations Coordinators, IT Client Operations, and others to review procedures and improve efficiency in claims adjudication.

Responsibilities include testing networks, ensuring accurate EFT/remittances, and recovering funds from pharmacies. You will monitor compliance with provider contracts, set up electronic payments/remits, and prepare reports on reimbursement and

Qualifications

• Associate Degree preferred or equivalent experience.
• CPhT preferred.
• PBM or managed care is preferred, but not required.
• Previous testing experience is preferred.
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees.

Responsibilities

• Administers technical processes in support of system price setups, electronic funds transfer and remittance setups according to policy
• Ensures appropriate controls and oversight reporting on the end-to-end process. If process controls are absent, the expectation is to identify, define, and implement new ones as needed
• Make decisions regarding the resolution of pharmacy network pricing setup issues. Research pricing inquiries from pharmacies and internal teams
• Develop processes to import and export data from Navitus systems, including the Pharmacy Credential and Contracting database and NCRx
• Responsible for pharmacy network rate testing, analysis and impact assessment
• Perform quality assurance to ensure accuracy in pharmacy network rates on an ongoing basis to mitigate the risk of incorrect claims adjudication
• Appropriately identify and elevate improper payments and 835 issues
• Maintenance of department detail work instructions and policies
• Monitoring and reporting of non-compliance relating to overpayments, transaction standard issues and financial regulations
• Provide offset detail to pharmacies impacted in a recovery project prior to receipt of payment and remit
• Responsible for oversight of applicable financial and metric's reporting, data dictionaries, inquiries, and audits
• Other duties as assigned

Education

Associate Degree or equivalent experience

CPhT preferred

Job description

Company

Navitus

About Us

Navitus - Putting People First in Pharmacy - Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.. Current associates must use SSO login option at https://employees-navitus.icims.com/ to be considered for internal opportunities. We are committed to providing equal employment opportunity to all applicants and employees and comply with all applicable nondiscrimination regulations, including those related to protected veterans and individuals with disabilities. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or handicap.

Pay Range

USD $48,728.61 - USD $58,010.26 /Yr.

STAR Bonus % (At Risk Maximum)

7.50 - Salaried Non-Management except pharmacists

Work Schedule Description (e.g. M-F 8am to 5pm)

M-F 8am to 5pm

Remote Work Notification

ATTENTION: Lighthouse is unable to offer remote work to residents of Alaska, Delaware, Hawaii, Idaho, Iowa, Louisiana, Maine, Mississippi, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Rode Island, South Carolina, South Dakota, Vermont, West Virginia, and Wyoming.

Overview

Navitus Health Solutions is seeking a Pharmacy Reimbursement Administrator to join our team! The Pharmacy Reimbursement Administrator (PRA) works in partnership with the Provider Relations Coordinators, IT Client Operations, and others to continually review, monitor, and update procedures to improve efficiencies of claims adjudication administration. The PRA will test and review pharmacy networks to ensure that claims are adjudicating per Navitus' pharmacy contract agreements. The PRA is responsible for the process of pharmacy remittances, including the accuracy of data in pharmacy electronic payments (EFT) and/or 835-remittance advice and the oversight of recoveries of funds from pharmacies. The PRA is responsible for recuperation of monies from pharmacy providers in negative balance status, as well as developing and providing reports to Navitus associates of all reimbursement, recovery, and remittance activities. Day-to-day activities include submitting service requests for any necessary network updates, auditing networks for price change accuracy, monitoring compliance with Navitus pharmacy provider contracts, setting up electronic payments and remits, and responding to questions related to payment issues. The individual in this position is expected to make independent assessments to confirm Navitus is conforming to contractual reimbursement obligations contained in pharmacy agreements.

Responsibilities

How do I make an impact on my team?

• Administers technical processes in support of system price setups, electronic funds transfer and remittance setups according to policy
• Ensures appropriate controls and oversight reporting on the end-to-end process. If process controls are absent, the expectation is to identify, define, and implement new ones as needed
• Make decisions regarding the resolution of pharmacy network pricing setup issues. Research pricing inquiries from pharmacies and internal teams
• Develop processes to import and export data from Navitus systems, including the Pharmacy Credential and Contracting database and NCRx
• Responsible for pharmacy network rate testing, analysis and impact assessment
• Perform quality assurance to ensure accuracy in pharmacy network rates on an ongoing basis to mitigate the risk of incorrect claims adjudication
• Appropriately identify and elevate improper payments and 835 issues
• Maintenance of department detail work instructions and policies
• Monitoring and reporting of non-compliance relating to overpayments, transaction standard issues and financial regulations
• Provide offset detail to pharmacies impacted in a recovery project prior to receipt of payment and remit
• Responsible for oversight of applicable financial and metric's reporting, data dictionaries, inquiries, and audits
• Other duties as assigned

Qualifications

What our team expects from you?

• Associate Degree preferred or equivalent experience. CPhT preferred
• PBM or managed care is preferred, but not required
• Previous testing experience is preferred
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program - up to $750!

#LI-Remote

Location : Address

Remote

Location : Country

US