Pharmacy Benefits Claims Specialist

Acrisure Trade Credit; Cadillac (MI); Presencial; USD 70.000 - 100.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical insurance

Dental insurance

Vision insurance

401(k) plan

Paid time off

Descripción de la vacante

Acrisure is seeking a Claims Consultant to support administration and processing of pharmacy benefit claims for self-funded employer health plans. You will serve as a liaison between clients, plan members, pharmacies, PBMs, TPAs, and internal teams to ensure accurate, efficient processing and regulatory compliance.

You will analyze claim issues, identify cost-saving opportunities, and deliver exceptional service to stakeholders.

Formación

• Bachelor’s degree preferred in business, healthcare administration, finance, insurance, public health, or related field.
• Minimum 3 years of experience in health insurance, pharmacy benefits, claims administration, healthcare operations, or related industry experience.
• Experience with self-funded health plans, PBMs, TPAs, or pharmacy benefit programs preferred.
• Strong verbal and written communication skills.
• Bilingual English/Spanish preferred, with ability to communicate with Spanish-speaking members and partners.

Responsabilidades

• Review, investigate, and resolve pharmacy benefit claim issues and inquiries in a timely manner.
• Analyze claim adjudication outcomes and identify discrepancies, processing errors, and corrective actions.
• Coordinate with pharmacies, PBMs, TPAs, carriers, brokers, and plan sponsors to resolve complex claim concerns.
• Research eligibility, benefit design, prior authorization requirements, and plan provisions to determine outcomes.
• Monitor claim payment accuracy and compliance with contractual and regulatory requirements.
• Assist in auditing and reconciliation of pharmacy claims data.
• Support client implementation projects and benefit plan changes.
• Maintain documentation of investigations, resolutions, and communications.
• Partner with Account Management, Clinical, and Operations teams to ensure service delivery.
• Provide education to members regarding claim processes, pharmacy benefits, and cost management.

Conocimientos

Bilingual English/Spanish

Excellent communication skills

Analytical thinking

Excel

Customer service

Educación

Bachelor’s degree in related field

Herramientas

Excel

Claims adjudication systems

Reporting platforms

Descripción del empleo

Acrisure is seeking a Claims Consultant to support administration and processing of pharmacy benefit claims for self-funded employer health plans. You will serve as a liaison between clients, plan members, pharmacies, PBMs, TPAs, and internal teams to ensure accurate, efficient processing and regulatory compliance.

You will analyze claim issues, identify cost-saving opportunities, and deliver exceptional service to stakeholders.