Administrator, Pharmacy Reimbursement at Navitus in Frankfort, Kentucky

Pharmacy Reimbursement AdministratorNavitus Health Solutions is seeking a Pharmacy Reimbursement Administrator to join our team!The Pharmacy Reimbursement Administrator (PRA) works in partnership with the Provider Relations Coordinators, IT Client Operations, and others to continually review, monitor, and update procedures to improve efficiencies of claims adjudication administration. The PRA will test and review pharmacy networks to ensure that claims are adjudicating per Navitus' pharmacy contract agreements. The PRA is responsible for the process of pharmacy remittances, including the accuracy of data in pharmacy electronic payments (EFT) and/or 835-remittance advice and the oversight of recoveries of funds from pharmacies. The PRA is responsible for recuperation of monies from pharmacy providers in negative balance status, as well as developing and providing reports to Navitus associates of all reimbursement, recovery, and remittance activities. Day-to-day activities include submitting service requests for any necessary network updates, auditing networks for price change accuracy, monitoring compliance with Navitus pharmacy provider contracts, setting up electronic payments and remits, and responding to questions related to payment issues. The individual in this position is expected to make independent assessments to confirm Navitus is conforming to contractual reimbursement obligations contained in pharmacy agreements.ResponsibilitiesAdministers technical processes in support of system price setups, electronic funds transfer and remittance setups according to policyEnsures appropriate controls and oversight reporting on the end-to-end process. If process controls are absent, the expectation is to identify, define, and implement new ones as neededMake decisions regarding the resolution of pharmacy network pricing setup issues. Research pricing inquiries from pharmacies and internal teamsDevelop processes to import and export data from Navitus systems, including the Pharmacy Credential and Contracting database and NCRxResponsible for pharmacy network rate testing, analysis and impact assessmentPerform quality assurance to ensure accuracy in pharmacy network rates on an ongoing basis to mitigate the risk of incorrect claims adjudicationAppropriately identify and escalate improper payments and 835 issuesMaintenance of department detail work instructions and policiesMonitoring and reporting of non-compliance relating to overpayments, transaction standard issues and financial regulationsProvide offset detail to pharmacies impacted in a recovery project prior to receipt of payment and remitResponsible for oversight of applicable financial and metric's reporting, data dictionaries, inquiries, and auditsOther duties as assignedQualificationsAssociate Degree preferred or equivalent experience. CPhT preferredPBM or managed care is preferred, but not requiredPrevious testing experience is preferredParticipate in, adhere to, and support compliance program objectivesThe ability to consistently interact cooperatively and respectfully with other employeesWhat can you expect from Navitus?Top of the industry benefits for Health, Dental, and Vision insurance20 days paid time off4 weeks paid parental leave9 paid holidays401K company match of up to 5% - No vesting requirementAdoption Assistance ProgramFlexible Spending AccountEducational Assistance Plan and Professional Membership assistanceReferral Bonus Program – up to $750!Navitus Health Solutions is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, creed, sex, pregnancy, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by law. Equal employment opportunity, including veterans and individuals with disabilities.