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Pharmacy High Cost Drug Analyst/Claims Examiner

Description

The High-Cost Drug Analyst is responsible for the investigation, invoicing and recovery of overpayments of high-cost/specialty drug claims paid through medical and pharmacy systems.  The analyst will also provide assistance in the development and testing of healthcare claim audits to assist clients in identifying payment errors on high-cost drug claims.


ESSENTIAL DUTIES & RESPONSIBILITIES


  • Assist in the development of the process/procedures for recovery of overpayment of high-cost/specialty drugs claims.

  • Assist in the research and testing of queries to refine the auditing process.

  • Identify potential recoverable claims and perform investigations to determine if claims are billable.

  • Assemble complete and accurate claims consistent with policies and procedures for submittal to medical provider or pharmacy for recovery.

  • Perform follow-up procedures to track the status of all claims submitted for recovery.  This will include preparing appropriate documentation of diary notes and monitoring recovery through final resolution.  Initiate escalation procedures for those providers that will not cooperate with the recovery process.

  • Process all recoveries received.  This includes reconciling paid to billed amounts at claim-level and preparing required Remittance and Write-Off Reporting.  In addition, perform further investigation of unidentified claim differences when applicable.



OTHER DUTIES & RESPONSIBILITIES



  • Performs other duties as assigned. 



SKILLS & ABILITIES 


  • Knowledge of high-cost/specialty drug coding, billing and claims payment processes.

  • Must be a self-starter that can provide input into the development of a new system to recover high-cost/specialty drug overpayments.

  • Demonstrates a high level of energy and persistence in implementing recovery processes and achieving production goals.

  • Effective communication skills and the ability to influence payers that have been invoiced.

  • Strong organizational skills and attention to detail in completion of responsibilities.

  • Strong analytical skills with an inquisitive and creative approach to problem solving.

  • Proficient in Microsoft Excel, Word and Access.


Requirements

 EXPERIENCE REQUIREMENTS 

  • Understanding of HCPCS and NDC drug claim coding and drug pricing.  Certified Coder helpful.

  • Background in specialty pharmacy, home infusion or home health background.

  • Minimum of three years progressive healthcare industry experience, with experience in billing and/or claim processing of high-cost drugs.

  •  


 EDUCATION REQUIREMENTS 


  • Bachelors’ degree in business, information systems, healthcare management or related field.


 
PHYSICAL REQUIREMENTS ESSENTIAL TO PERFORM THE DUTIES OF THE JOB 


  • Frequently remains in sitting position for long periods of time to perform duties.

  • Frequently concentrates for long periods of time, paying close attention to detail.

  • Frequently uses and views the computer using fingers, hands, and vision.

  • Frequently works in a well-lit, tempered environment.

  • Frequently utilizes mental capabilities to identify, evaluate, and assimilate information.

  • Occasionally walks though office to communicate with other employees.

  • Seldom lifts objects with weight up to (twenty-five (25) pounds such as files or paper boxes.





Equal Opportunity Employer 

Job Snapshot

Location US-KY-La Grange
Employment Type Full-Time
Pay Type Year
Pay Rate $42,000.00 /Year
Store Type Insurance, Pharmaceutical, General Business
Other Compensation: + Bonus Opportunity
Apply

Company Overview

The Rawlings Group

The Rawlings Group was formed in 1977 to offer legal services to insurance providers. Recognizing the need for specialized recovery services, Rawlings launched what would ultimately become the first subrogation outsourcing program for the healthcare industry. We subsequently launched other outsourcing programs specifically dedicated to medical claims recovery, mass tort litigation, and pharmaceutical claims recovery.

Contact Information

US-KY-La Grange

Snapshot
The Rawlings Group
Company:
US-KY-La Grange
Location:
Full-Time
Employment Type:
Year
Pay Type:
$42,000.00 /Year
Pay Rate:
Insurance, Pharmaceutical, General Business
Store Type:

Description

The High-Cost Drug Analyst is responsible for the investigation, invoicing and recovery of overpayments of high-cost/specialty drug claims paid through medical and pharmacy systems.  The analyst will also provide assistance in the development and testing of healthcare claim audits to assist clients in identifying payment errors on high-cost drug claims.


ESSENTIAL DUTIES & RESPONSIBILITIES


  • Assist in the development of the process/procedures for recovery of overpayment of high-cost/specialty drugs claims.

  • Assist in the research and testing of queries to refine the auditing process.

  • Identify potential recoverable claims and perform investigations to determine if claims are billable.

  • Assemble complete and accurate claims consistent with policies and procedures for submittal to medical provider or pharmacy for recovery.

  • Perform follow-up procedures to track the status of all claims submitted for recovery.  This will include preparing appropriate documentation of diary notes and monitoring recovery through final resolution.  Initiate escalation procedures for those providers that will not cooperate with the recovery process.

  • Process all recoveries received.  This includes reconciling paid to billed amounts at claim-level and preparing required Remittance and Write-Off Reporting.  In addition, perform further investigation of unidentified claim differences when applicable.



OTHER DUTIES & RESPONSIBILITIES



  • Performs other duties as assigned. 



SKILLS & ABILITIES 


  • Knowledge of high-cost/specialty drug coding, billing and claims payment processes.

  • Must be a self-starter that can provide input into the development of a new system to recover high-cost/specialty drug overpayments.

  • Demonstrates a high level of energy and persistence in implementing recovery processes and achieving production goals.

  • Effective communication skills and the ability to influence payers that have been invoiced.

  • Strong organizational skills and attention to detail in completion of responsibilities.

  • Strong analytical skills with an inquisitive and creative approach to problem solving.

  • Proficient in Microsoft Excel, Word and Access.


Requirements

 EXPERIENCE REQUIREMENTS 

  • Understanding of HCPCS and NDC drug claim coding and drug pricing.  Certified Coder helpful.

  • Background in specialty pharmacy, home infusion or home health background.

  • Minimum of three years progressive healthcare industry experience, with experience in billing and/or claim processing of high-cost drugs.

  •  


 EDUCATION REQUIREMENTS 


  • Bachelors’ degree in business, information systems, healthcare management or related field.


 
PHYSICAL REQUIREMENTS ESSENTIAL TO PERFORM THE DUTIES OF THE JOB 


  • Frequently remains in sitting position for long periods of time to perform duties.

  • Frequently concentrates for long periods of time, paying close attention to detail.

  • Frequently uses and views the computer using fingers, hands, and vision.

  • Frequently works in a well-lit, tempered environment.

  • Frequently utilizes mental capabilities to identify, evaluate, and assimilate information.

  • Occasionally walks though office to communicate with other employees.

  • Seldom lifts objects with weight up to (twenty-five (25) pounds such as files or paper boxes.





Equal Opportunity Employer 
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