Pharmacy/Billing Technician

American Health Partners; Franklin (TN); On-site; USD 36,000 - 48,000; Full time

Job summary

American Health Plans is hiring a Pharmacy Technician to support member access in claims adjudication for a Medicare Advantage I-SNP. You will review POS claims, resolve action items, and coordinate with external pharmacy and claims teams to ensure accurate adjudication and payment.

Join a team focused on COB, PA processes, and CMS guidelines, handling documentation, audits, and continuous process improvement across billing workflows.

Qualifications

• Minimum 2 years as a Pharmacy technician, long term care, or health plan experience.
• Experience with pharmacy claims, rejections, and prior authorizations (PA).
• Ability to navigate multiple systems and maintain compliance with CMS regulations.

Responsibilities

• Review daily POS pharmacy claims and resolve actionable items.
• Investigate and resolve claim rejections and payment discrepancies.
• Collaborate with external pharmacy and claims teams to ensure accurate adjudication and payment.
• Facilitate the prior authorization process with prescribers, pharmacies, and internal staff.

Skills

Analytical skills

Communication

MS Office proficiency

Education

High school diploma or equivalent

Tools

Microsoft Office

Job description

JOB SUMMARY

The Pharmacy Technician for American Health Plans is responsible for activities related to member access in the area of claims adjudication appropriateness and operations performed by the Plan's Pharmacy Benefit Manager for a Medicare Advantage Institutional Special Needs Plan (I-SNP).

ESSENTIAL JOB DUTIES

• Review daily point-of-service (POS) pharmacy claims, resolve actionable items, track, and provide reporting
• Investigate and resolve pharmacy claim rejections, reversals, and payment discrepancies in real time.
• Collaborate with external pharmacy and claims teams to ensure accurate claim adjudication and payment.
• Submit and track claim overrides when appropriate and compliant with plan and CMS guidelines.
• Ensure proper coordination of benefits (COB), hospice billing considerations, and Part A/B vs Part D determinations when applicable.
• Facilitate the prior authorization process by working with prescribers, pharmacies, and internal clinical staff.
• Gather and submit required documentation for PA review and ensure completeness to minimize delays.
• Monitor PA status and proactively communicate determinations and next steps to pharmacies and providers.
• Serve as primary billing and claims contact for contracted network and long-term care pharmacies.
• Communicate professionally with pharmacy billing teams, prescribers, and facility staff to resolve claims issues.
• Educate pharmacies and provider offices on billing requirements, formulary limitations, and plan processes.
• Support transitions of care by ensuring medication access and clean claim processing for new or discharged members.
• Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies.
• Accurately document all claim interventions, communications, and resolutions in the plan's system.
• Assist with internal audits, reporting, and quality improvement initiatives related to claims and billing.
• Identify trends in claim rejections or PA delays and recognize systemic issues to leadership.
• Monitor daily billing and claims work queues and meet productivity and turnaround time expectations.
• Participate in cross-functional meetings with pharmacy operations, clinical, and provider relations teams.
• Support process improvement initiatives to enhance claims efficiency and member access to medications.
• Serve as a liaison with Enrollment Department to assure appropriate member eligibility processing
• Recognize formulary requirements: prior authorization (PA), Step Therapy (ST), Quantity Limit (QL) and understand NCPDP reject codes
• Coordinate clinical reporting
• Follow-up and solve open items in a timely manner
• May be assigned to work on special projects and business initiatives
• Other duties as assigned

JOB REQUIREMENTS

• Proficient with Microsoft Suite applications
• Ability to navigate multiple systems
• Strong analytical skills
• Proficient communication and presentation skills
• Adhere to Centers of Medicare and Medicaid Services (CMS) regulations and compliance requirements
• Successful completion of required training

REQUIRED QUALIFICATIONS

• Education:
  • High school diploma or equivalent
• Experience:
  • Minimum of 2 years as a Pharmacy technician, long term care, or health plan experience
  • Experience in planning and implementation
  • Experience working pharmacy claims, rejections, and PA's
• License/Certification(s):
  • Pharmacy Technician certification preferred

Equal Opportunity Employer

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For further information, please review the Know Your Rights notice from the Department of Labor.