Pharmacy Reimbursement Specialist

- East Syracuse, NY
Posted: June 17, 2022
Overview:
Scope of Responsibilities: Works under minimal supervision within Accounting and Finance department to ensure timely review of data for reporting to stores, outside Third-Party Business partners, as well as government agencies. Prepares reports and maintains various files and information for the department ensuring proper reimbursement.

Job Summary: Assists and supports the Accounting and Finance department in the achievement of Rx sales, gross margin according to plan.

Responsibilities:
Job Duties:

Responsible for reviewing, identifying and correcting billing issues based on contractual agreements

Responsible for PBM related billing communications regarding better reimbursement strategies and issues faced to all locations.

Assist in auditing plans to verify contractual compliance

Responsible for monitoring MAC pricing and submitting MAC appeals daily and developing and maintaining MAC reporting and analysis

Responsible for using daily/weekly/monthly reports for Third Party billing and pricing accuracy to maintain the highest level of profitability.

Responsible for monitoring and sending claims via the AWP resubmission tool and analysis reporting of outcomes

Assist in reviewing, analyzing, and developing edits internally and through our switch that can improve efficiencies and/or profitability

Assist in the development and preparation of all claims related and profitability reporting.

Assist Third Party Administrator/Reimbursement Manager in the review of plan set up within the pharmacy application

Assist Operations in the Pay for Performance programs and DIR improvement through increased STAR ratings

Assists Third Party Administrator/ Reimbursement Manager with development and distribution of third-party training programs.

Responsible for completing all mandatory and regulatory training programs

Perform other duties as assigned

Qualifications:
Experience Preferred:

Previous experience in store pharmacy operations, Third Party operations, and/or Administrative Assistant duties

Educational Requirements:

Minimum: High School Diploma or GED

Preferred: AS Degree or Higher in Business Administration, or related field

Special Conditions of Employment:

Criminal background check

Drug Test

Initial and continuous exclusion and sanction/disciplinary monitoring


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East Syracuse, NY

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