Pharmacy/Billing Technician

American Health Plans; Franklin (TN); On-site; USD 42,000 - 52,000; Full time

Benefits offered by this job

Equal Opportunity Employer

Job summary

American Health Plans in Franklin, TN is seeking a Pharmacy Technician to support claims adjudication, COB, PA processes, and billing within the Medicare Advantage I-SNP program.

The role focuses on reviewing POS claims, resolving rejections, collaborating with pharmacies and CMS guidelines, and ensuring accurate claim processing while maintaining CMS/HIPAA compliance.

Qualifications

• 2+ years as a Pharmacy Technician or health plan experience
• Experience with pharmacy claims, rejections, and PA processes
• Familiarity with CMS regulations and HIPAA compliance

Responsibilities

• Review daily pharmacy claims and report outcomes
• Investigate claim rejections, reversals, and payment discrepancies in real time
• Collaborate with external pharmacy and claims teams for accurate adjudication
• Submit and track overrides per plan and CMS guidelines
• Coordinate benefits and determine Part A/B vs Part D applicability
• Support PA processes with prescribers, pharmacies and staff

Skills

MS Office

System navigation

Analytical

Communication

CMS compliance

Training

Education

High school diploma

Job description

American Health Plans
Franklin, TN 37067, USA

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:

To perform this job, an individual must perform each essential function satisfactorily, with or without a reasonable accommodation.

• 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 escalation 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
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.