Claims Specialist Team Lead
Job Description
Overview
PharMerica, a part of Brightspring Health Services, is a long‑term care pharmacy services provider that supplies medications, clinical support, and pharmacy management to healthcare organizations across the United States.
The 3rd Party Claims Specialist Team Lead is a subject matter expert (SME) on the company’s denial research methods, internal and external databases, reporting tools and policies and procedures. The Team Lead is a SME on all types of denials and functions performed by both the Claims Specialist I and Claims Specialist II and acts as a trainer and mentor to both.
Shift: Nights and Weekends
Remote position
Benefits and perks for You!
- Medical, Dental, Vision insurance
- Health Savings & Flexible Spending Accounts (up to $5,000 for childcare)
- Tuition discounts & reimbursement
- 401(k)
- Company Paid Time Off*
- Shift Differential
- DailyPay
- Pet Insurance
- Employee wellness and discount programs
*Benefits may vary by employment status
Responsibilities
- Trains new employees and ensures all applicable training materials are provided and reviewed
- Provides support to staff and acts as a mentor/coach to promote a positive environment
- Provides feedback on all levels of staff to supervisor to be used in employees one on ones, check-ups and reviews
- Identifies staff performance issues and discuss with Supervisor
- Provides the necessary re-training or one on one support with staff to assist in meeting the performance expectations
- Assists management with fair distribution of work/site assignments being sure to communicate when the workloads are off balance and make suggestions on how to reconcile
- Reviews variances and write-offs submitted by staff for accuracy of information and approval requirements before giving to Supervisor for approval
- Performs monthly quality assessments on staff to ensure accuracy. Report any identified training needs to Supervisor and Manager for further review and follow-up action plan as needed
- Prepares and maintain reports and records for processing as well as run and produce miscellaneous reports as assigned or necessary
- Identifies potential financial exposure and risk to the company with underperforming or non-compliant payers
- Stays up to date on third-party billing requirements
- Monitors and provide support to those assigned to work convert billing exception reports to ensure claims are billed to accurate financial plans timely
- Completes billing transactions for non standard order entry situations as required
- Provides education to management and team members on payer specific claim processing rules, reimbursement, and other policy guidelines as gleaned by, and confirmed through working directly with payers
- Takes initiative to find opportunities and make suggestions for process improvement within the department
Qualifications
EDUCATION/EXPERIENCE
• High School graduate, GED or equivalent experience.
• Desired: Associates degree, 4 year college or technical degree.
• 3+ years insurance billing experience.
• Specialized understanding of billing requirements in one of the following areas: Medicare Part D, Medicaid, and Commercial billing.
• Understanding of revenue cycle functions within pharmacy practice or equivalent setting.
LICENSE/CERTIFICATION/OTHER SPECIAL REQUIREMENTS
• Desired: Pharmacy Technician.
KNOWLEDGE/SKILLS/ABILITIES
• Strong analytical skills, excellent time management and attention to details.
• Working knowledge in MS Office Products (Excel, Word) and basic computer knowledge.
• Comfortable making phone calls and interacting with internal/external entities.
• AS400, Frameworks or QS1, Computer Systems Experience.
• Communication, problem solving, detail oriented and teamwork, customer service, and accuracy.
• Strong organization skills, self-starter, and confidence.
• Must be a positive mentor to all staff.
*This position will require sitting, standing, and walking. It will also require frequent typing on a keyboard. Ability to push/pull 21-30 lbs, and carry up to 21-30 lbs.*
