Pharmacy/Billing Technician

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

📋 Description

• Review daily pharmacy claims at the point of service, resolve actionable items, monitor activity, and generate reports.

• Investigate and address pharmacy claim rejections, reversals, and payment discrepancies in real time.

• Collaborate with external pharmacy and claims teams to ensure precise claim adjudication and payment.

• Submit and oversee claim overrides in accordance with plan and CMS guidelines.

• Ensure appropriate coordination of benefits, hospice billing considerations, and determinations between Part A/B and Part D.

• Facilitate prior authorization processes with prescribers, pharmacies, and internal clinical personnel.

• Collect and submit documentation for prior authorization reviews; monitor status and communicate results.

• Act as the primary billing and claims liaison for contracted networks and long-term care pharmacies.

• Educate pharmacies and provider offices on billing requirements, formulary limitations, and plan procedures.

• Assist in transitions of care by ensuring medication access and accurate claim processing.

• Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies.

• Document claim interventions, communications, and resolutions within the plan’s system.

• Support internal audits, reporting, and initiatives for quality improvement.

• Identify trends in claim rejections and prior authorization delays, escalating systemic issues to leadership.

• Monitor daily billing and claims work queues, meeting productivity and turnaround time expectations.

• Engage in cross-functional meetings with pharmacy operations, clinical, and provider relations teams.

• Contribute to process improvement initiatives aimed at enhancing claims efficiency and member medication access.

• Coordinate with the Enrollment Department concerning member eligibility processing.

• Recognize formulary requirements including prior authorization, Step Therapy, Quantity Limits, and NCPDP reject codes.

• Oversee clinical reporting.

• Follow up on and resolve outstanding items promptly.

• Participate in special projects and business initiatives.

• Perform additional duties as assigned.

⛳️ Requirements

• High school diploma or equivalent required.

• At least 2 years of experience as a Pharmacy Technician, preferably in long-term care or health plan settings.

• Familiarity with pharmacy claims, rejections, and prior authorizations (PAs).

• Experience in planning and implementation.

• Proficient in Microsoft Suite applications.

• Ability to navigate through multiple systems.

• Strong analytical skills.

• Effective communication and presentation abilities.

• Compliance with Centers for Medicare and Medicaid Services (CMS) regulations and requirements.

• Successful completion of required training.

• Pharmacy Technician certification is preferred.

🏝️ Benefits

• Reasonable accommodations available for applicants with disabilities.

• Full-time remote work arrangement offered.