Representative, PFM

Under the direction of a Supervisor, the Representative in PFM Business Intelligence is a member of the Business Intelligence team and is responsible for auditing contract and MAC exceptions and supporting client initiatives. Duties include identifying MAC, pricing and contract exceptions, submitting appeals to the carriers, recording responses from the carriers, preparing standard reporting, interacting with numerous internal and external parties, cross-training with other team members, pulling data and adding MAC appeals information for QBRs and MBRs, product testing and uploading claims and tagging in the Audit Management Application.

Primary Accountabilities:

• Analytical
   

  • Understand the nature of retail pharmacy

  • Monitor the data to ensure that the carriers adjusted reimbursement

  • Run reports and create uploads to vet and submit claims for MAC appeals

  • Create and deliver standard MAC reporting on a weekly basis to the client

  • Technical

  • Use data visualizations appropriately and effectively

  • Identify, develop and implement new procedures to increase efficiency and productivity of work processes

  • Participate in product grooming, perform and lead user acceptance testing

  • Produce reports and other requested deliverables including financial analysis

  • Design internal and external facing dashboards for trending and benchmarking

• Operational
   

  • Contact clients for invoices when needed; fax invoices and supporting documentation to the carriers

  • Run reports and create uploads to vet and submit claims for MAC appeals

  • Upload claims in the Audit Management App

  • Tag claims for Audits in the Pharmacy Management tool

  • Pursue MAC appeals and Contract exceptions using the Contract Management App and Business Intelligence tools

  • Follow documented best practices for submitting MAC and Contract exceptions to the carriers

  • Participate in agile missions to improve processes

  • Support the Product teams in relation to product enhancements:Identifying product enhancements that would be beneficial for clients

  • Performing user acceptance testing on product enhancements

• Administrative
   

  • Pull data for Quarterly Business Reviews and Monthly Business Reviews

  • Pull data for ad hoc analysis

  • Record the responses from the carriers, potential savings and cost adjustments in the application

  • Keep abreast of state level MAC legislation

  • Follow up with the carriers after submitting appeals in a timely manner

  • Continue to update MAC Appeals forms, spreadsheets, procedures, etc in the MAC Google Drive site

  • Share MAC results with the team

  • Maintain HIPAA (Health Insurance Portability and Accountability Act) compliance in all client communication

  • Perform special projects and other duties as assigned by management

Additional Responsibilities:

• Performs other duties as assigned

• Complies with all policies and standards

Required Qualifications:

• 1-3 years At least 2 years of relevant experience involving customer service, computer usage, data entry and data analysis AND an Associate’s degree in Business Administration, Accounting, or a related field; OR an equivalent combination of training and experience required to complete the essential functions/job responsibilities of the position required

• Proficient in Microsoft Office Suite, Microsoft Windows

• Competent in 10 Key Manual Entry, Google Office Suite

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We are an Equal Opportunity Employer, including disability/vets.