Part D Claims Specialist

This is a fully remote position, open to applicants in Colorado.

📋 Description

• Oversee and reconcile Part A claims and patient stays.

• Execute Part D compliance responsibilities, including B vs D, ESRD, and Medical Necessity evaluations.

• Manage the participant plan enrollment status with pharmacies and PBMs.

• Ensure that claims are billed to Part D in accordance with CMS regulations and EMR documentation.

• Download and analyze weekly, monthly, and quarterly Part D and PBM reports, taking necessary actions.

• Download and review CMS reports and implement required actions.

• Reconcile rejected claims and address submission issues with pharmacies and PBMs.

• Assist in reconciling PDE data.

• Summarize and report on PDE progress.

• Prepare, submit, and analyze PDE submissions to CMS.

• Remain updated on pharmacological advancements and Medicare Part D guidelines.

• Collaborate with Medicare and Medicaid specialists as necessary.

• Work alongside finance and billing specialists to resolve billing issues.

• Manage provider credentials for the PBM and contracted pharmacies.

• Carry out additional duties as required.

• Operate independently in a remote work environment while handling large data volumes.

⛳️ Requirements

• A minimum of 3 years of experience with medical and/or pharmacy claims.

• Comprehensive knowledge of medication names, dosages, indications, and routes of administration.

• Proficient in navigating EMR systems and interpreting EMR data.

• Advanced Excel capabilities for managing extensive data, including formulas, pivots, and reports.

• Ability to troubleshoot and resolve issues under pressure.

• Strong attention to detail with the capacity to prioritize tasks effectively.

• Comfortable working autonomously.

• Exceptional communication and organizational skills.

• Proficient in computer applications, including word processors, spreadsheets, and database software.

• Associate’s degree or equivalent formal training beyond high school in lieu of an Associate’s degree.

• Applicants from Florida must undergo background screening through the Florida Care Provider Background Screening Clearinghouse.

• Preferred: experience with EPIC EMR.

• Preferred: experience in managing patient plan eligibility.

• Preferred: experience in a PACE or similar healthcare program.

• Preferred: understanding of Medicare Part D regulations and compliance requirements.

• Bachelor’s degree is preferred.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Short- and long-term disability insurance.

• Life insurance and Accidental Death & Dismemberment (AD&D) coverage.

• Supplemental life insurance options.

• Flexible spending accounts.

• 401(k) savings plan with company matching contributions.

• Paid time off.

• Company-paid holidays.

• Equal opportunity and affirmative action workplace.

• Diverse and inclusive work environment.

• Patient-centered care model.

• Remote work position.