Pharmacy Claims Representative 2

Description Must be able to work: Monday - Friday, 2:30pm to 11pm EST plus every fourth weekend Essential Functions _Note: The essential duties and primary accountabilities below are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Incumbents may perform all or most of the primary accountabilities listed below. Specific tasks, responsibilities or competencies may be documented in the incumbentu2019s performance objectives as outlined by the incumbentu2019s immediate supervisor or manager._ 1. Assist pharmacies with real-time and retrospective claims adjudication. Adjust and correct authorizations in dispensing and PBM systems to ensure timely claims submission. Research and resolve rejected claims by contacting hospices for approvals or updated authorizations. 2. Maintain accuracy of patient profiles, involving authorization status and relatedness indicators. 3. Evaluate and process compound medication claims, ensuring accuracy in ingredients, quantities, and pricing. 4. Research pharmacy invoices and hospice billing issues, reconciling discrepancies as needed. 5. Collaborate with the Customer Service team on complex claims research and resolution. 6. Understand Enclara Pharmaciau2019s standard and custom formularies and differentiate between Per Diem (PD) and Fee-for-Service (FFS) billing models across hospice partners. 7. Contact facilities and pharmacies to verify and collect necessary information for onboarding spreadsheets. Coordinate PBM and billing system verification with facility pharmacies. Maintain and update facility-pharmacy tracking spreadsheets and communicate status with implementation teams. 8. Educate facility pharmacies on billing procedures and contacts for rejected claims. 9. Collect and verify missing or incomplete facility information reported by the Call Center team. Ensure all facilities are correctly linked to their respective hospices in internal systems. Assist with Confirmation Fax reports to validate and update facility-pharmacy relationships and demographics. 10. Complete tasks and special projects assigned by Pharmacy Claims Team Leaders on Pharmacy Claims (Support Services) Manager. 11. Support Call Center leadership in initiatives to streamline processes and improve service outcomes. Marginal or Additional Functions 1. Performs other duties as assigned or apparent. Supervisory and Managerial Responsibility u2022 Supervisory/managerial responsibility is not applicable Knowledge, Skills & Abilities Education, Licensure or Certification: u2022 High school diploma or equivalent required u2022 CPhT or EXCPT certification preferred Work Experience or Related Experience: u2022 Minimum of six (6) months of pharmacy technician experience. u2022 Experience with pharmacy claims adjudication is required. Specialized Knowledge, Skills & Abilities: u2022 PBM or billing platform experience preferred u2022 Proficient in Microsoft Office Suite, especially Excel, Word, Outlook, and Access u2022 Comfortable navigating multiple software systems, including pharmacy dispensing and PBM platforms u2022 Excellent verbal and written communication skills u2022 Ability to learn proprietary systems used for claims management and facility tracking. Equipment u2022 Working knowledge of a PC, business and communications software (MS Office) and web-based tools are required Travel Requirements and Conditions u2022 Travel is not required Work Environment, Conditions and Demands u2022 Work is generally performed in a climate-controlled, smoke-free office environment. Physical Requirements and Demands u2022 May sit, stand, walk, stoop, or bend intermittently throughout the day. u2022 May be required to sit for extended periods (7-10 hours/day). u2022 Occasional lifting of up to 25 pounds may be required. u2022 Requires manual dexterity to operate office equipment. u2022 Visual acuity to read fine print and digital screens; must be able to hear and respond to verbal communication. Additional Position Information u2022 No additional information is applicable Qualifications Education Required + High School or better Licenses & Certifications Preferred + CPhT or EXCPT Experience Required + Experience with pharmacy claims adjudication is required. Preferred + Minimum of six (6) months of pharmacy technician experience. Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights ( notice from the Department of Labor.

Created: 2026-01-19