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  • Pharmacy Claims Specialist

    Biloxi, MS 39532

    Posted: 05/12/2023 Industry: Pharmacy Technician Job Number: 9 Pay Rate: $15-16/hr

    Job Description

    Position Overview:

    Under the direct supervision of the Director of Pharmacy Services, the Pharmacy Claims Specialist is responsible for the reconciliation of pharmacy third-party claims, investigating denied, non-matched unpaid and/or underpaid claims, and posting claim reconciliation and receivables within pharmacy data system.  Conducts routine administrative and clerical tasks such as answering the phones, filing documents, ordering supplies, stocking shelves, and processing insurance and self-pay payments.  Assists in the administration of 340B and other medication-related patient assistance programs.  Performs additional duties as required by supervisory personnel.



    Biloxi, Mississippi 

    Job Type:

    Full Time

    Monday through Friday 8a-5p



    Qualifications/Education Requirements:

    • Must have a high school diploma or equivalent and 1-2 years of experience in a pharmacy setting.
    • Graduation from a formal training program is preferred but will accept equivalent work experience in lieu of. 
    • Must be Nationally Certified by Pharmacy Technician.
    • 1-2 years of Medicare and Medicaid billing and appeals experience.



    Job Requirements

    Knowledge, Skills, and Abilities:

    • The ability to utilize a personal computer and applicable department/organizational software.
    • The ability to exercise sound judgment and possess strong problem-solving skills.
    • The ability to ask probing questions and obtain thorough and relevant information.
    • The ability to deliver highly technical information to less technical individuals.
    • Knowledge of the most common brand and generic drug names.
    • Knowledge of third-party prescription claims adjudication programs and processes.
    • Knowledge of managed care principles and reimbursement policies and procedures.
    • Knowledge of basic medical terminology and understanding of the National Drug Code (NDC).
    • Knowledge of 340B program and regulations governing administration and compliance.
    • Knowledge of Mississippi Board of Pharmacy and Federal controlled substances regulations.
    • Must have effective verbal and written communication skills and demonstrate the ability to
      work well within a team.
    • Must demonstrate professional and ethical business practices, adherence to company
      standards, and a commitment to personal and professional development.
    • Proven time management skills and the ability to work in a production focused environment are a must.
    • Must demonstrate the ability to manage multiple priorities or tasks, deliver timely and accurate work products with a customer service focus, and respond with urgency as required – Must perform all other duties as assigned.

    Core Competencies:

    • Generating monthly statements, processing and entering payments, and reconciling third-party claims through the pharmacy data system accounts receivable.
    • Assisting the Accounting Department in collecting data for claims audits.
    • Serve as a subject matter expert for complicated processing for prescriptions.
    • Work cross functionally with other departments and shifts with auto-billing and other queues.
    • Claims adjustments and review.
    • Understanding of Medicare Part D, commercial insurance, and Medicaid.
    • Adjudicating insurance claims and troubleshooting rejected claims.
    • Completing prior authorization forms if necessary.
    • Ensure compliance of 340B pharmacy and third-party billing practices.
    • Prescription data entry and filling of medication orders as required.
    • Providing customer service through phones, checking emails and messages to pharmacy and responding promptly and professionally.
    • Communication with insurance parties via inbound and outbound calls.
    • Analyzing pre- and post- adjudication reports for training opportunities and compliance.
    • Must be able to sit or stand for extended periods of time and to lift items greater than 40 pounds above shoulders.
    • May require frequent bending of knees and back.
    • Must possess a valid driver’s license, reliable transportation, and willingness to travel to different pharmacy locations as required.
    • Performs other duties as requested and/or required.

    Upholds, complies with, and enforces the Core Principles and Code of Conduct.

    Essential Job Accountabilities:

    1. Practice within legal scope of State law and National Standards.
    2. Provides essential job functions to maintain safe and
      effective day-to-day services.
    3. Participates as a team member to help achieve pharmacy goals, organizational standards, and customer satisfaction.
    1. Provides excellent customer service.
    2. Performs other related duties as assigned or requested


    Accountability 1.  Practice within legal scope of State law and National Standards

    Performance criteria 1: Adhere to dispensing scope of practice requirements as outlined in the Mississippi Pharmacy Practice Act. 

    Performance criteria 2: Keeps active and in-date national certification status by the Pharmacy Technician Certification Board.

    Performance criteria 3: Successful completion of skills/competency certification requirements.

    Performance criteria 4: Performance of duties will be in compliance with all laws, regulations, policies and procedures governing Coastal Family Health Center Pharmacy.


    Accountability 2. Provides essential job functions to maintain effective day-to-day services

    Performance Criteria 1: Accurately interprets all medication orders and dispenses to patients in a safe and timely manner.

    Performance Criteria 2: Works cooperatively with third-party claims administrators to adjudicate denied or rejected claims.

    Performance Criteria 3: Works cooperatively with CFHC administrative support staff to ensure patient claims are processed and funds received and recorded.

    Performance Criteria 4: Efficiently utilizes approved resources in day-to-day activities.

    Performance Criteria 5: Documents and acts on all medication recall notices to ensure complete patient safety.

    Performance Criteria 6: Ensures that all prescriptions processed are checked by Registered Pharmacist prior to dispensing to patients.

    Performance Criteria 7: Ensures patient confidentially at all times.

    Performance Criteria 8:  Ensures that all dispensing related functions are contained within the scope of Article XL of the Mississippi Pharmacy Practice Act.


    Accountability 3.  Participates as a team member to help achieve pharmacy goals, organizational standards, and customer satisfaction

    Performance criteria 1: Provides feedback to supervisory personnel for process improvement.

    Performance criteria 2: Demonstrates the knowledge of quality services and best practices to promote positive patient outcomes.

    Performance criteria 3: Possesses sound listening skills and demonstrates tolerance and a non-judgmental attitude toward all patients and staff members.

    Performance criteria 4: Respects and supports the Patient’s Bill of Rights by demonstrated behaviors consistent with that document.

    Performance criteria 5: Demonstrates a positive attitude, exhibits professionalism, and adheres to Coastal’s Code of Conduct.

    Performance criteria 6: Shows commitment to personal and professional growth through additional training, education, and skills development.

    Performance criteria 7: Ensures regular and timely attendance.


    Accountability 4. Provides excellent customer service

    Performance criteria 1: Demonstrates appropriate telephone etiquette.

    Performance criteria 2:  Provides timely and appropriate follow up to all provider, patient, and outside customer messages.

    Performance criteria 3: Consistently demonstrates common courtesy and respect to patients, family members, providers and co-workers in all communications.  


    Accountability 5. Performs other related duties as assigned or requested

    Performance criteria 1: Contributes to the daily operation of Coastal’s operations by performing other roles as needed.

    Performance criteria 2: Completes special duties/projects as assigned



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