- Reconcile and manage Part A claims and stays
- Perform Part D compliance tasks, including B vs D, ESRD, Medical Necessity, etc.
- Download and review weekly, monthly and quarterly Part D and PBM (Pharmacy Benefits Manager) reporting and take necessary actions
- Download and review CMS reports and take necessary actions
- Reconcile rejected claims and submission concerns with pharmacies and PBM
- Assist in the reconciliation of PDE (Prescription Drug Event) data
- Summarize and report PDE progress
- Prepare, submit, and analyze PDE submissions to CMS
- Stay current on pharmacological updates and Medicare Part D Guidelines
- Coordinate with Medicare and Medicaid specialists as needed
- Work with finance and billing specialists on bill resolution
- Manage provider credentials for our PBM and contracted pharmacy
- Perform other duties as needed
- 3+ yrs working with medical and/or pharmacy claims.
- Current advanced knowledge in medication names, dosages, indications, and routes of administration.
- Experience and comfort navigating EMR and interpreting EMR data
- Advanced skills using Excel to manage large volumes of data - formulas, pivots, reports
- Ability to solve problems under pressure
- Strong attention to detail and able to prioritize workload
- Comfortable working independently
- Excellent communication and organization skills
- Strong computer skills including word processors, spreadsheets, and database software.
- Associates degree or formal training beyond high school in lieu of Associates
- Bachelors degree
- Experience in EPIC EMR
- Experience managing patient plan eligibility
- Experience in a PACE or similar healthcare program
- Knowledge of Medicare Part D regulations and compliance requirements
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Part D Claims Eligibility Specialist - Denver, United States - InnovAge
Description
Responsibilities:
The Part D Claims Eligibility Specialist is responsible for performing a range of tasks related to claims and compliance for the InnovAge Part D plan. This includes managing and reconciling Part A claims and stays, managing participant plan enrollment status with the pharmacy and PBM, ensuring that claims are billed to Part D appropriately based on CMS regulations and EMR documentation, and working closely with Medicare, Medicaid, finance, and billing specialists. The role requires being detail oriented, comfortable managing large volumes of data and working independently.
Work-from-Home position.
REQUIRED
PREFERRED
The mission of InnovAge is to allow seniors to live life on their terms by aging in place, in their own homes and communities, for as long as safely possible. InnovAges Program of All-inclusive Care for the Elderly (PACE) is an alternative to nursing facilities. Our enrolled participants receive customized healthcare and social support at a nearby PACE center supported by a team of medical experts dedicated to providing personalized healthcare and support to help them age at home. Our greatest assets are our team members who make a difference in the lives of those we serve every day. Elevate your future with co-workers passionate about a patient-centered care model supported by comprehensive services to improve the quality of care while reducing over-utilization of high-cost care settings.
As an equal opportunity/affirmative action employer InnovAge is committed to and values an inclusive and diverse workplace. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, sexual orientation, gender, gender identity/expression, national origin, disability or protected veteran status, pregnancy or any other status prohibited by applicable law.
Salary ranges are dependent on a variety of factors, including qualifications, experience, and geographic location and does not include potential bonus or benefits. Comprehensive benefits include m/d/v, short and long-term disability, life insurance and AD&D, supplemental life insurance, flexible spending accounts, 401(k) savings, paid time off, and company paid holidays.
Posted Salary Range:USD $ USD $32.45 /Hr.
