Medication Claims Reviewer

Medication Claims Reviewer

Under the supervision of the Director of 340B Program, the Medication Claims Reviewer shall perform chart reviews to locate chart notes, consultations, medications and referral orders to support 340B claims. The Medication Claims Reviewer will work with team members, clinic staff and physicians to ensure all requirements are met.

It is the primary purpose of CHCCC to provide the highest quality of total care possible to the patient population it serves. Such a level of quality depends ultimately on the staff's desire and ability to work together, individually, and as a team. The employee is expected to be professional, punctual, maintain regular attendance, cooperative, motivated, and organized at all times.

Essential duties and responsibilities include the following. Additional duties may be assigned with or without prior notice.

• Uses 340B reports to identify patient charts that require review for chart notes, consultations, medication documentation and referral orders.
• Performs chart review, identifies presence or absence of required elements.
• Works with Specialty offices or Referral Department to retrieve the missing consultation documentation.
• Contacts pharmacies to obtain a copy of the prescription when the consultation documentation does not include medication referenced in 340B claims report.
• Uses pharmacology references to determine generic from brand name prescription drugs.
• Works with office staff, medication case managers and physicians to ensure medication reconciliation is completed to reflect medications from 340B claims report.
• Works with office staff and physicians to ensure referral order is in chart for patients seen by and receiving prescription drugs from consulting specialist.
• Faxes consultations and prescription slips to Athena for scanning into patient's EMR.
• Works with 340B team to verify 340B claims reports.
• Demonstrates professionalism and provides quality customer service using AIDET Standards.
• Ability to work with high volume of patients, internal/external customers, and deal with frequent changes, delay or unexpected events.
• Record 340B receivables.
• Demonstrates adherence to and observes all safety policies and procedures.
• Demonstrates knowledge of domestic violence, child and dependent abuse protocols.
• Demonstrates cultural sensitivity and competence with patients.
• Maintains and adheres to HIPAA, employee confidentiality, and privileged communications (patient, employee, and corporation).

This job has no supervisory responsibilities.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Understanding of accounting, finance or pharmacy operations

High school diploma or GED required. Finance background preferred.

Ability to read, analyze, and interpret documents such as safety rules, operating and maintenance instructions, policy and procedure manuals. Ability to respond effectively to the most sensitive inquires or complaints. Ability to write routine reports and correspondence. Ability to speak effectively before groups of patients or employees of organization.

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Ability to apply sound judgment in understanding to carry out instructions in written or oral form. Ability to make appropriate job decisions following standard office policies and past precedents.

Experience with word processing, spreadsheets, email, and keyboarding required. Microsoft Office and Google Suite skills required. Excellent command of Excel and working knowledge of EHR preferred.

Possession of current, valid, unrestricted California Driver's License (Class C) required.

Required to pass a criminal history background check and drug screen upon hire. Annual health examination; annual Tuberculosis skin test clearance or chest x-ray; proof of immunity to MMR, Varicella, and Hepatitis B; proof of Tdap vaccine; during current flu season, must provide proof of influenza vaccine or a signed declination form. If declined, a flu mask is mandatory during flu season.

While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee occasionally is required to sit. The employee is occasionally required to stand and walk for extended periods of time. The employee may occasionally lift and/or move up to 10 pounds of supplies. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

While performing the duties of this job, the employee is occasionally exposed to moving mechanical parts. The employee is occasionally exposed to risk of electrical shock. The noise level in the work environment is moderate (i.e. office setting with computers, phones, and printers). Must be able to work in a fast-paced environment.

Must be willing to have a flexible work schedule that may include evenings/weekends, and travel as needed.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified.