Claims Review Pharmacist

Davita Inc.; United States; Remote; USD 60,000 - 90,000; Part time

Job summary

A leading healthcare provider is seeking an experienced 1099 Claims Review Pharmacist. This pivotal role involves the resolution of claims disputes and requires strong clinical experience as well as proficiency in navigating documentation. Successful candidates will demonstrate excellent communication skills and a high level of professionalism. If you have a solid background in clinical care and are adept at maintaining confidentiality, we encourage you to apply for this opportunity.

Benefits

Flexible working hours

Work from home options

Qualifications

• Five years full-time equivalent experience providing direct clinical care to patients.
• Experience providing direct clinical care within the past three years.
• Hold a non-restricted license in any US state.

Responsibilities

• Conduct impartial assessment of documentation from both parties.
• Review medical documentation for medical necessity.
• Adhere to company policies and guidelines.

Skills

Organizational abilities

Written communication

Verbal communication

Ability to work independently

Ability to work collaboratively

Education

Licensed in required Specialty

Tools

Microsoft Excel

Microsoft Word

Microsoft Outlook

Job description

About Capitol Bridge
Founded in 2012, Capitol Bridge is based in Arlington, Virginia and has proven expertise providing independent medical reviews, records/data management services, medical coding, administrative staffing and eligibility reviews.

Capitol Bridge is actively seeking an experienced 1099 Claims Review Pharmacist. The Claims Review Position will play a crucial role in the fair and efficient resolution of claim disputes.

You will be responsible for resolving claim disputes submitted by various parties such as physicians, hospitals, institutions, pharmacies, and other licensed healthcare providers. Additionally, provide assistance to contracted and non-contracted health care providers and health care plans for resolution of claims disputes. Your role requires conducting all job duties efficiently, promptly, productively, consistently, and courteously, while maintaining a high level of professionalism.

Salary Range:Approximately $250 per case depending on case requirements.

Key Responsibilities:

Conduct impartial assessment of documentation from both initiating and responding parties.

Review medical documentation to make a determination of the medical necessity or appropriateness of each service/procedure listed in a dispute.

Utilize governmental and professional guidelines to support the determination on medical necessity or appropriateness of each service/procedure listed in a dispute.

Adhere to company policies, state regulations, and specific project guidelines.

Maintain effective communication.

Ensure timely completion of reviews within assigned deadlines.

Follow established QA/QC processes and meet company/departmental standards.

Uphold scheduling commitments and privacy regulations.

Perform other related duties as directed by leadership.

Required Qualifications:

Licensed in required Specialty.

Five years full-time equivalent experience providing direct clinical care to patients

Experience providing direct clinical care to patients within the past three years

Hold a non-restricted license in any state in the US and for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the condition or treatment under review

Preferred Qualifications:

Familiarization with claims

Knowledge of claim review processes

Familiarization with navigating electronic documents like PDFs, Microsoft Excel, Microsoft Word and experience using Microsoft Outlook.

Exceptional skills in managing sensitive and confidential information.

Strong organizational abilities, written, and verbal communication skills in English.

Ability to work both independently and collaboratively.

Skilled in prioritizing tasks to align with business needs and assignments.

Required Screenings
You will receive a request for a background check regarding this employment opportunity. Employment is contingent on successful passing of a background check.

Reasonable Accommodation
If you require alternative methods of application or screening, you must approach the employer directly to request this. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions. Other duties may be assigned.

EEO Statement
Capitol Bridge LLC. is an Equal Opportunity Employer. All employment decisions at Capitol Bridge are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion or belief, national, social, or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate.

Texting Notice
We communicate with applicants by text in addition to email and phone. If you apply for this position, we may text you about this position, your application for the position, or other things relevant to this job position. If we text you and you no longer want us to text you, you can opt-out at that time.