Taunton, MA - 3rd Party Claims Specialist - B&C - 8197

  • Sector: Healthcare
  • Contact: Vaishali Sharma
  • Client: IMS People Possible
  • Location: Taunton, United States of America
  • Salary: Negotiable
  • Expiry Date: 03 October 2022
  • Job Ref: BBBH394140_1657062563
  • Contact Email: vsharma@medicalrecruitmentstrategies.com


Ensure maximum reimbursement by resolving payer rejected claims with critical deadlines while adhering to compliance standards and mitigating financial risk to PharMerica and our customers in a high volume, fast paced environment.

Essential Functions:

Manage and identify a portfolio of rejected pharmacy claims to ensure maximum payer reimbursement and timely billing to eliminate financial risks to PharMerica and their customers.
Research, analyze and appropriately resolve rejected claims by working with national Medicare D plans, third party insurance companies and all state Medicaid plans to ensure maximum payer reimbursement adhering to critical deadlines.
Ensure approval of claims by performing appropriate edits and/or reversals to ensure maximum payer reimbursement.
Contact providers and/or customers as necessary to obtain additional information needed for claims processing.
Monitor and resolve at risk revenue associated with payer set up, billing, rebilling, and reversal processes.
Work as a team to identify, document, communicate and resolve payer/billing trends and issues
Timely complete, communicate and submit necessary payer paperwork including but not limited to benefit eligibility assessment, claim to old overrides and manual claim forms.
When necessary, will rebill claims electronically in accordance with NCPDP standards, online through payer specific websites, manually through Universal Claim Forms, or through other approved methods for favorable resolution of denied claims
Review and work convert billing exception reports to ensure claims are billed to accurate financial plans.
Complete billing transactions for non-standard order entry situations as required.
Consistently meets productivity metrics and performance standards
Prepares and maintains reports and records for processing.
Performs other related duties as assigned
Conducts job responsibilities in accordance with the standards set out in the Company's Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.

Education/Learning Experience

Required: High School graduate, GED, or equivalent experience

Desired: Associates degree, 4-year college or technical degree

Work Experience

Required: 1 year insurance billing experience

Desired: Third Party Billing or collections/billing experience in the healthcare industry

Desired: General understanding of billing requirements for Medicare Part D, Medicaid, and Commercial billing

Desired: Understanding of revenue cycle functions within pharmacy practice or equivalent setting


Required: Strong Analytical Skills, Excellent time management and attention to details

Required: Working knowledge in MS Office Products (Excel, Word) and basic computer knowledge

Required: Comfortable making phone calls and interacting with internal/external entities

Desired: AS400, Frameworks or QS1, Computer Systems Experience


Required: N/A

Desired: Pharmacy Technician

Behavior Competencies

Required: Communication, Problem Solving, Detail Oriented and Teamwork, Customer Service, and Accuracy.

Required: Strong organization skills, self-starter, and confidence


Monday to Friday 8:05 AM to 5:05 PM Day Shift