Job Details

ID #19639426
State Pennsylvania
City Philadelphia
Job type Permanent
Salary USD TBD TBD
Source Amerihealth
Showed 2021-09-15
Date 2021-09-02
Deadline 2021-11-01
Category Et cetera
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Quality Analyst

Pennsylvania, Philadelphia, 19107 Philadelphia USA

Vacancy expired!

Job Brief - Review claims to ensure accurate claim processing according to Medicare Part D benefit & policy - National Pharmacy Technician Certification (ExCPT, NCCT, PTCB) required - Min 3 yrs current/recent retail pharmacy experience required

Your career starts now. We're looking for the next generation of health care leaders. At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you. Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

PerformRx is a Pharmacy Benefits Manager (PBM) dedicated to clinical culture, boutique service and holistic solutions. Our mission is to help customers, doctors and patients use effective medication therapy to improve health and wellness. For more than 15 years, our focus has been on providing optimal service through a clinical culture which seeks to provide members with high quality care while ensuring our partners receive favorable costs. That culture is reflected in our employees; more than 80 percent of our staff members are Pharmacists and Pharmacy Technicians, and in the services we provide. PerformRx is headquartered in Philadelphia. Our dedication to innovation and to providing the most efficacious outcomes is the core of our clinical culture and is the heart of PerformRx. PerformRx is a subsidiary of the AmeriHealth Caritas Family of Companies.

Summary: The primary role of the Quality Analyst is to review claims to ensure accurate claim processing according to Medicare Part D benefit and policy.

Responsibilities:
  • Analyze, investigate, review, forecast, trend and present information for compliance and fraud, waste, and abuse planning
  • Conduct and manage issue identification and validate correction through the claim monitoring processes
  • Communicate issues identified to the Business Process Lead and/or Manager, providing explanations and interpretations of complex and ambiguous data and outcomes, and perform additional claim and benefit impact analysis as necessary
  • Review daily claim files to determine appropriate benefit/claim administration is being delivered by the PBM
  • Understand the overall business model of Medicare Part D products, CMS guidance, and the PBM claim adjudication system

Education/Experience:
  • High School Diploma or equivalent required; Bachelor's degree preferred
  • Active/current National Pharmacy Technician Certification (ExCPT, NCCT, PTCB) required
  • Minimum three (3) years of current/recent professional retail pharmacy experience required
  • Pharmacy Benefit Manager (PBM), Medicare (Part D), fraud, call center experience preferred

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