[Hiring] Part D Claims Specialist @InnovAge

Role Description

The Part D Claims Eligibility Specialist is responsible for performing a range of tasks related to claims and compliance for the InnovAge Part D plan. This includes:

• Managing and reconciling Part A claims and stays
• Managing participant plan enrollment status with the pharmacy and PBM
• Ensuring that claims are billed to Part D appropriately based on CMS regulations and EMR documentation
• Working closely with Medicare, Medicaid, finance, and billing specialists
• Being detail oriented and comfortable managing large volumes of data
• Working independently

Work-from-Home position.

• Reconcile and manage Part A claims and stays
• Perform Part D compliance tasks, including B vs D, ESRD, Medical Necessity, etc.
• Download and review weekly, monthly and quarterly Part D and PBM (Pharmacy Benefits Manager) reporting and take necessary actions
• Download and review CMS reports and take necessary actions
• Reconcile rejected claims and submission concerns with pharmacies and PBM
• Assist in the reconciliation of PDE (Prescription Drug Event) data
• Summarize and report PDE progress
• Prepare, submit, and analyze PDE submissions to CMS
• Stay current on pharmacological updates and Medicare Part D Guidelines
• Coordinate with Medicare and Medicaid specialists as needed
• Work with finance and billing specialists on bill resolution
• Manage provider credentials for our PBM and contracted pharmacy
• Perform other duties as needed

Qualifications

• 3+ years working with medical and/or pharmacy claims
• Current advanced knowledge in medication names, dosages, indications, and routes of administration
• Experience and comfort navigating EMR and interpreting EMR data
• Advanced skills using Excel to manage large volumes of data - formulas, pivots, reports
• Ability to solve problems under pressure
• Strong attention to detail and able to prioritize workload
• Comfortable working independently
• Excellent communication and organization skills
• Strong computer skills including word processors, spreadsheets, and database software
• Associate’s degree or formal training beyond high school in lieu of Associates

Requirements

• Bachelor’s degree (preferred)
• Experience in EPIC EMR (preferred)
• Experience managing patient plan eligibility (preferred)
• Experience in a PACE or similar healthcare program (preferred)
• Knowledge of Medicare Part D regulations and compliance requirements (preferred)

Benefits

• Medical/dental/vision insurance
• Short and long-term disability
• Life insurance and AD&D
• Supplemental life insurance
• Flexible spending accounts
• 401(k) savings
• Paid time off
• Company-paid holidays