Pharmacy/Billing Technician

🕒 May 20

🎸 Tennessee – Remote

🎸 Tennessee – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

📊 Billing Specialist

🚫👨‍🎓 No degree required

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American Health Partners

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1976

⚕️ Healthcare Insurance

Healthcare Insurance

American Health Partners is a healthcare organization focused on improving access to and coordination of high-quality care through a continuum of services tailored to institutional and special-needs populations. The company operates institutional special needs health plans and provides specialized care coordination, geriatric inpatient and acute psychiatric care, and pharmacy services for long-term-care facilities, supported by an owned/affiliated network of locations and thousands of contracted providers. American Health Partners emphasizes convenient, preventive care to reduce costly hospital stays and improve patient outcomes and quality of life.

📋 Description

• Review daily point-of-service (POS) pharmacy claims, resolve actionable items, track, and provide reporting • Investigate and resolve pharmacy claim rejections, reversals, and payment discrepancies in real time • Collaborate with external pharmacy and claims teams to ensure accurate claim adjudication and payment • Submit and track claim overrides when appropriate and compliant with plan and CMS guidelines • Facilitate the prior authorization process by working with prescribers, pharmacies, and internal clinical staff • Monitor PA status and proactively communicate determinations and next steps to pharmacies and providers • Serve as primary billing and claims contact for contracted network and long-term care pharmacies • Communicate professionally with pharmacy billing teams, prescribers, and facility staff to resolve claims issues • Educate pharmacies and provider offices on billing requirements, formulary limitations, and plan processes • Support transitions of care by ensuring medication access and clean claim processing for new or discharged members • Maintain compliance with CMS Medicare Part D regulations, HIPAA, and plan policies • Accurately document all claim interventions, communications, and resolutions in the plan’s system • Assist with internal audits, reporting, and quality improvement initiatives related to claims and billing • Identify trends in claim rejections or PA delays and escalate systemic issues to leadership • Monitor daily billing and claims work queues and meet productivity and turnaround time expectations • Participate in cross-functional meetings with pharmacy operations, clinical, and provider relations teams • Support process improvement initiatives to enhance claims efficiency and member access to medications • Serve as a liaison with Enrollment Department to assure appropriate member eligibility processing • Recognize formulary requirements: prior authorization (PA), Step Therapy (ST), Quantity Limit (QL) and understand NCPDP reject codes • Coordinate clinical reporting • Follow-up and solve open items in a timely manner • May be assigned to work on special projects and business initiatives

🎯 Requirements

• High school diploma or equivalent • Minimum of 2 years as a Pharmacy technician, long term care, or health plan experience • Experience in planning and implementation • Experience working pharmacy claims, rejections, and PA’s • Proficient with Microsoft Suite applications • Strong analytical skills • Proficient communication and presentation skills • Adhere to Centers of Medicare and Medicaid Services (CMS) regulations and compliance requirements • Successful completion of required training

🏖️ Benefits

• Equal Opportunity Employer