Remote Pharmacy Reimbursement Administrator

Florida Pharmacy Association, Inc.; Tallahassee (FL); Remote; USD 60,000 - 80,000; Full time

Benefits offered by this job

Health, dental, vision insurance

Paid time off (20 days)

Parental leave (4 weeks)

Holidays (9)

401K match up to 5%

Adoption Assistance

Flexible Spending Account

Educational & Membership assistance

Referral Bonus up to $750

Job summary

Navitus Health Solutions is seeking a Pharmacy Reimbursement Administrator to join our team. The PRA collaborates with Provider Relations Coordinators, IT Client Operations, and others to review and update procedures to improve claims adjudication efficiency.

The role tests and reviews pharmacy networks to ensure claims adjudicate per Navitus' contract agreements, oversees remittances, EFTs, and 835 remittance data, and helps recover funds from pharmacies in negative balance status.

Qualifications

• Associate degree preferred or equivalent experience.
• CPhT preferred.
• PBM or managed care experience preferred.
• Previous testing experience preferred.
• Support compliance program objectives.

Responsibilities

• Administers technical processes in support of system price setups, EFT and remittance setups according to policy.
• Ensures appropriate controls and oversight reporting on the end-to-end process. If process controls are absent, identify, define, and implement new ones as needed.
• Make decisions regarding the resolution of pharmacy network pricing setup issues. Research pricing inquiries from pharmacies and internal teams.
• Develop processes to import and export data from Navitus systems, including the Pharmacy Credential and Contracting database and NCRx.
• Responsible for pharmacy network rate testing, analysis and impact assessment.
• Perform quality assurance to ensure accuracy in pharmacy network rates on an ongoing basis to mitigate the risk of incorrect claims adjudication.
• Appropriately identify and elevate improper payments and 835 issues.
• Maintenance of department detail work instructions and policies.
• Monitoring and reporting of non-compliance relating to overpayments, transaction standard issues and financial regulations.
• Provide offset detail to pharmacies impacted in a recovery project prior to receipt of payment and remit.
• Responsible for oversight of applicable financial and metric's reporting, data dictionaries, inquiries, and audits.
• Other duties as assigned.

Skills

Associate Degree

CPhT

PBM experience

Testing experience

Compliance

Education

Associate Degree

Tools

Navitus systems

Job description

Navitus Health Solutions is seeking a Pharmacy Reimbursement Administrator to join our team. The PRA collaborates with Provider Relations Coordinators, IT Client Operations, and others to review and update procedures to improve claims adjudication efficiency.

The role tests and reviews pharmacy networks to ensure claims adjudicate per Navitus' contract agreements, oversees remittances, EFTs, and 835 remittance data, and helps recover funds from pharmacies in negative balance status.