Pharmacy Claims Adjudication Specialist

The Controls and QA Analyst is responsible for developing, monitoring, assessing, reviewing, and recommending changes to Livinitis quality and control procedures to ensure the highest quality standards in accordance with company policies. The Controls and QA Analyst works closely with the Claims Processing Director, the Claims Processing team, and the other members of the Controls and QA team. This role is heavily analytical and requires critical thinking skills.

• Responsible for providing quality assurance for internal processes and suggesting additional additions, when appropriate.
• Understands and defines the performance and quality standards expected of Claims Processing employees.
• Evaluates quality standards from an objective point of view and ensures the proper checks and balances are applied to all parts of the Claims Processing procedures.
• Responsible for being fully trained in both the claims processor and other internal programs so an adequate knowledge base can be used when evaluating and following procedures.
• Participate in the design of procedures of but not limited to reimbursement audits, group/plan design, in-house ticket, group/plan changes, SOC audits, and QA testing in internal program(s).
• Remain current on plan knowledge, policies, processes, procedures, and systems knowledge of Southern Scripts procedures.
• Contribute to the continual evaluation, identify, and solve for inefficiencies of existing processes and procedures.
• Create a culture of continuous improvement.
• Potentially responsible for providing training internal teams on new procedures implementing updated quality controls.
• Assist with group/plan design, when necessary.
• Managing tickets and accurately capture/categorize necessary trend information.
• Support projects and initiatives which drive department strategy.
• Share and communicate pertinent information with internal team members and internal partners.
• Utilizing an in depth understanding of technical principles, theories, and concepts in the field of quality to perform a thorough root cause and corrective action analysis.
• Assist with User Acceptance Testing for internal program development before enhancements are released.
• Familiar with external teams regarding test platform claims data/enhancement requests.
• Analyze and interpret test claims for processing and adjudication results to ensure configuration accuracy.
• Assist with other departments troubleshooting plan/benefit configuration related questions through claims testing.
• Report findings and follow through with resolution resulting from claims analysis.
• Document results and follow through resolution within departments tracking system.
• Participate in a culture of continuous improvement, open door policy and internal support system.
• Be example for work ethic, growth, positivity, and external team communications.
• Ensure daily tasks performed by team meet quality and expectations of dept leaders.
• Continuous involvement in claims analysis with QA team.
• Abide by all obligations under HIPAA related to Protected Health Information (PHI).
• If a HIPAA violation is discovered, whether individually or by another, you must report the violation to the Compliance Officer and/or Human Resources.
• Attend, complete, and demonstrate competency in all required HIPAA Training offered by the company.
• Flexibility to understand, appreciate and embrace that this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change, or new ones may be assigned at any time with or without notice.

• Problem Solving/Analysis.
• Critical Thinking.
• Time Management.
• Communication.
• Objectivity.
• Technical Expertise.
• Perform root cause analysis.
• Strong written and verbal communication skills.
• Exceptional listening and analytical skills.
• Proficient in Word, Excel, and PowerPoint for presentations and reports required.

Our benefits package is designed to keep our employees happy and healthy - physically, mentally and financially

• Medical, Dental and Vision insurance
• Disability and Life insurance
• Employee Assistance Program
• Generous Paid-Time Off
• Annual Reviews and Development Plans
• Retirement Plan with company match immediately 100% vested
  
  

Supervisory Responsibility

No supervisory responsibility is expected for this position.

• Full-time, salary/exempt position.
• Some flexibility in hours is allowed, but the employee must be available during the core work hours of 8:00AM to 5:00PM CT Monday through Friday. We cover clients from West to East Coast, work times must be adjusted to cover meetings in all time zones. Ability to work extended hours, weekends and holidays pursuant with industry demands.

Minimal travel expected for this position to Natchitoches, Louisiana for training and development.

• 2 years of PBM experience in a Quality Analysis and Controls setting OR
• 3 years of PBM experience in Benefit Design execution or Implementation at a high level.

• Bachelors degree.
• 5 years QA experience in a PBM setting.

Liviniti, LLC and all entities provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, Liviniti complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Liviniti expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of Liviniti employees to perform their job duties may result in discipline up to and including discharge. EOE M/F/V/D

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