Acrisure združuje zavarovanje, upravljanje tveganj in finančne storitve za posameznike, podjetja in zaposlene. Njena ponudba vključuje osebno in poslovno zavarovanje, hipotekarna posojila, ugodnosti za zaposlene, kibernetsko varnost, upravljane IT-storitve in pozavarovanje, pri čemer je slednje usmerjeno tudi na mednarodni trg. Podjetje povezuje svetovalno strokovno znanje s tehnološko podprtimi rešitvami v širokem portfelju storitev ter vlaga tudi v partnerstva s skupnostmi in dejavnosti za njihovo podporo.
Pharmacy Benefits Claims Consultant
Resolve pharmacy benefit claims for self-funded employer health plans by investigating discrepancies and coordinating with stakeholders. Support accurate claims processing and improvements to plan performance and cost management.
Opis
- Investigate and resolve pharmacy benefit claim issues and inquiries.
- Review claim outcomes to find discrepancies, processing errors, and opportunities for corrective action.
- Coordinate on complex claim concerns with pharmacies, PBMs, TPAs, carriers, brokers, and plan sponsors.
- Research eligibility, benefit design, prior authorization rules, and plan provisions to determine claim outcomes.
- Track payment accuracy and compliance with contractual and regulatory requirements.
- Help audit and reconcile pharmacy claims data.
- Support client implementations and benefit plan changes.
- Document claim investigations, resolutions, and communications.
- Work with Account Management, Clinical, and Operations teams to deliver coordinated service.
- Explain claim processes, pharmacy benefits, and cost management strategies to members.
- Keep current with pharmacy benefit trends, industry regulations, and healthcare legislation affecting claims administration.
- Carry out other assigned duties.
Zahteve
- Preferred: bachelor’s degree in business, healthcare administration, finance, insurance, public health, or a related field.
- At least three years of experience in health insurance, pharmacy benefits, claims administration, healthcare operations, or a related industry.
- Experience with self-funded health plans, PBMs, TPAs, or pharmacy benefit programs is preferred.
- A comparable combination of education and experience may be considered.
- Strong spoken and written communication skills.
- English and Spanish fluency is preferred.
- Solid knowledge of healthcare claims processing and pharmacy benefit administration.
- Knowledge of prescription drug benefit structures, formularies, specialty pharmacy programs, and utilization management.
- Strong analytical and problem-solving abilities.
- Able to assess urgency independently, prioritize work, research and resolve issues, determine when to escalate, follow through promptly, and communicate clearly.
- Careful attention to detail and commitment to accuracy.
- Strong customer service and relationship management skills.
- Professional communication with members, pharmacies, providers, and internal teams.
- Proficiency in Microsoft Office, especially Excel.
- Experience with claims adjudication systems, reporting platforms, and healthcare data is preferred.
- Able to learn quickly and adapt.
- Strong organizational and documentation skills.
- Comfortable working on-site to support collaboration, team leadership, and cross-functional partnerships.
Ugodnosti
- Comprehensive medical insurance
- Dental insurance
- Vision insurance
- Life and disability insurance
- Fertility benefits
- Wellness resources
- Paid sick time
- Generous paid time off and holidays
- Employee Assistance Program (EAP)
- Complimentary Calm app subscription
- Immediate vesting in a 401(k) plan
- Health Savings Account (HSA) options
- Flexible Spending Account (FSA) options
- Commuter benefits
- Employee discount programs
- Paid maternity leave
- Paid paternity leave, including for adoptive parents
- Legal plan options
- Pet insurance coverage