Claims Specialist Team Lead

PharMerica; Louisville (KY); Remote; USD 60,000 - 90,000; Full time

Benefits offered by this job

Medical, Dental, Vision insurance

Health Savings & Flexible Spending

Tuition discounts & reimbursement

401(k)

Company Paid Time Off

Shift Differential

DailyPay

Pet Insurance

Employee wellness and discountPrograms

Job summary

PharMerica, part of BrightSpring Health Services, seeks a 3rd Party Claims Specialist Team Lead to act as SME on denial research, assist with payer rules, and mentor staff. The role supports evening/weekend shifts in a remote setting across the United States, focusing on improving billing accuracy and compliance.

Responsibilities include staff training, performance feedback, and process improvements, with emphasis on Medicare Part D, Medicaid, and commercial billing.

Qualifications

• High School graduate, GED or equivalent experience.
• Desired: Associates degree, 4 year college or technical degree.
• 3+ years insurance billing experience.
• Specialized understanding of billing requirements (Medicare Part D, Medicaid, Commercial).
• Revenue cycle knowledge in pharmacy settings.

Responsibilities

• Trains and mentors staff to ensure training materials are used.
• Supports staff and promotes a positive environment.
• Provides feedback to supervisors for performance reviews.
• Identifies performance issues and discusses with Supervisor.
• Provides retraining and coaching to improve performance.
• Assists management with fair work distribution and workload balance.
• Reviews variances and write-offs for accuracy before Supervisor approval.
• Performs monthly quality assessments and reports findings.
• Maintains processing reports and generates necessary reports.
• Identify financial exposure and risk with non-performing payers.
• Keep up-to-date on third-party billing requirements.
• Monitor and support billing exception reports to ensure correct payer reimbursements.
• Complete billing transactions for non-standard orders when required.
• Educate management on payer-specific claim rules and guidelines.
• Proactively suggest process improvements within the department.

Skills

Analytical skills

Time management

Attention to detail

MS Office

Phone communication

Customer service

Problem solving

Teamwork

Education

High school diploma

Associates or higher

Tools

AS400

QS1

Frameworks

Job description

Our Company

PharMerica

Overview

PharMerica, a part of Brightspring Health Services, is a long‑term care pharmacy services provider that supplies medications, clinical support, and pharmacy management to healthcare organizations across the United States.

The 3rd Party Claims Specialist Team Lead is a subject matter expert (SME) on the company’s denial research methods, internal and external databases, reporting tools and policies and procedures. The Team Lead is a SME on all types of denials and functions performed by both the Claims Specialist I and Claims Specialist II and acts as a trainer and mentor to both.

Shift: Evening and Weekends

Remote position

Benefits and perks for You!

• Medical, Dental, Vision insurance
• Health Savings & Flexible Spending Accounts (up to $5,000 for childcare)
• Tuition discounts & reimbursement
• 401(k)
• Company Paid Time Off*
• Shift Differential
• DailyPay
• Pet Insurance
• Employee wellness and discount programs

*Benefits may vary by employment status

Responsibilities

• Trains new employees and ensures all applicable training materials are provided and reviewed
• Provides support to staff and acts as a mentor/coach to promote a positive environment
• Provides feedback on all levels of staff to supervisor to be used in employees one on ones, check-ups and reviews
• Identifies staff performance issues and discuss with Supervisor
• Provides the necessary re-training or one on one support with staff to assist in meeting the performance expectations
• Assists management with fair distribution of work/site assignments being sure to communicate when the workloads are off balance and make suggestions on how to reconcile
• Reviews variances and write-offs submitted by staff for accuracy of information and approval requirements before giving to Supervisor for approval
• Performs monthly quality assessments on staff to ensure accuracy. Report any identified training needs to Supervisor and Manager for further review and follow-up action plan as needed
• Prepares and maintain reports and records for processing as well as run and produce miscellaneous reports as assigned or necessary
• Identifies potential financial exposure and risk to the company with underperforming or non-compliant payers
• Stays up to date on third-party billing requirements
• Monitors and provide support to those assigned to work convert billing exception reports to ensure claims are billed to accurate financial plans timely
• Completes billing transactions for non standard order entry situations as required
• Provides education to management and team members on payer specific claim processing rules, reimbursement, and other policy guidelines as gleaned by, and confirmed through working directly with payers
• Takes initiative to find opportunities and make suggestions for process improvement within the department

Qualifications

• EDUCATION/EXPERIENCE
• High School graduate, GED or equivalent experience.
• Desired: Associates degree, 4 year college or technical degree.
• 3+ years insurance billing experience.
• Specialized understanding of billing requirements in one of the following areas: Medicare Part D, Medicaid, and Commercial billing.
• Understanding of revenue cycle functions within pharmacy practice or equivalent setting.
• LICENSE/CERTIFICATION/OTHER SPECIAL REQUIREMENTS
• Desired: Pharmacy Technician.
• KNOWLEDGE/SKILLS/ABILITIES
• Strong analytical skills, excellent time management and attention to details.
• Working knowledge in MS Office Products (Excel, Word) and basic computer knowledge.
• Comfortable making phone calls and interacting with internal/external entities.
• AS400, Frameworks or QS1, Computer Systems Experience.
• Communication, problem solving, detail oriented and teamwork, customer service, and accuracy.
• Strong organization skills, self-starter, and confidence.
• Must be a positive mentor to all staff.

*This position will require sitting, standing, and walking. It will also require frequent typing on a keyboard. Ability to push/pull 21-30 lbs, and carry up to 21-30 lbs.*

About our Line of Business

PharMerica, an affiliate of BrightSpring Health Services, delivers personalized pharmacy care through dedicated local teams, serving health care providers such as skilled nursing facilities, senior living communities, and hospitals. We also cater to individuals with behavioral needs, infusion therapy needs, seniors receiving in-home care, and patients with cancer. Operating long-term care, home infusion, and specialty pharmacies across the nation, we combine the personal touch of a neighborhood pharmacy with the resources of a national network. Our comprehensive solutions, backed by industry-leading technology and regulatory expertise, ensure accurate medication access, cost control, and compliance with best-in-class clinical standards. We are committed to enhancing resident health, reducing staff burdens, and supporting our clients' success. For more information, visit www.pharmerica.com. Follow us on Facebook, Twitter, and LinkedIn.