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Senior Pharmacy Claims Recovery Specialist

2 months ago

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At Conduent Payment Integrity Solutions Inc., we pride ourselves on delivering essential services and solutions for Fortune 100 companies and numerous government entities, ensuring outstanding results for our clients and the communities they serve.

As a Senior Pharmacy Claims Recovery Specialist, you will play a pivotal role in executing intricate tasks in accordance with established protocols, utilizing your analytical and organizational skills to effectively manage assignments.

This position involves the recovery of overpayments from various stakeholders, including pharmacies, pharmacy benefit managers (PBMs), healthcare facilities, and insurance providers, specifically focusing on pharmacy claims that have been erroneously compensated.

Key Responsibilities:

  • Lead the recovery efforts for pharmacy claim overpayments through direct communication methods such as phone, email, or fax.
  • Utilize advanced expertise in analytical methods and operational processes to enhance recovery outcomes.
  • Coordinate the work of junior team members, providing guidance and support as needed.
  • Develop effective strategies and workflows to optimize recovery opportunities.
  • Communicate with PBMs regarding Medicare Secondary Payer requirements and drug exclusions under Medicare Part D.
  • Document all recovery efforts in the appropriate systems and manage disputes and appeals from providers and clients.
  • Prepare claims for client offsets and interface with clients as necessary.
  • Mentor less experienced team members and act as a subject matter expert in pharmacy billing and insurance collections.

Qualifications:

  • Strong background in pharmacy billing concepts and claim recovery.
  • Extensive knowledge of insurance procedures, including interactions with PBMs and various insurance carriers.
  • Familiarity with third-party reimbursement types and healthcare reimbursement across different settings.
  • Professional verbal and written communication skills.
  • Advanced proficiency in Excel and a minimum of five years of experience in pharmacy billing or insurance collections.

Education:

Associate degree or equivalent combination of education and experience.

At Conduent, we are committed to providing a diverse and inclusive workplace. We welcome applicants from all backgrounds and experiences, ensuring equal opportunity for all candidates.