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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at [ Link removed ] - Click here to apply to Pharmacy Benefits Claims Analyst.
PerformRx is a Pharmacy Benefits Manager (PBM) dedicated to clinical culture, boutique service and holistic solutions. Our mission is to help customers, doctors and patients use effective medication therapy to improve health and wellness. For more than 15 years, our focus has been on providing optimal service through a clinical culture which seeks to provide members with high quality care while ensuring our partners receive favorable costs. That culture is reflected in our employees; more than 80 percent of our staff members are Pharmacists and Pharmacy Technicians, and in the services we provide.
PerformRx is headquartered in Philadelphia with offices on both coasts, leading to better pharmacy benefit management across the nation. Our dedication to innovation and to providing the most efficacious outcomes is the core of our clinical culture and is the heart of PerformRx. PerformRx is a subsidiary of the AmeriHealth Caritas Family of Companies.
To maintain, review, and provide consultation on basic to moderately complex customer benefits. The Benefit Claims Analyst also analyzes claims reports to identify trends, issues, and present recommendations.
Maintains strong knowledge of Commercial and Exchange-Related Benefit Designs including a familiarity with Commercial Benefits Configurations with both Medical and Pharmacy-Combined Benefit Designs.
Maintains knowledge of Medicare and Medicaid-related benefit designs, including knowledge of CMS guidance and regulations applicable to Pharmacy Benefits.
Maintains knowledge of Coordination of Benefits and determining pharmacy payment liability between multiple payers, including Medicare, Medicaid and Commercial Pharmacy Benefits.
Researches benefit and claims related inquiries from PerformRx clients and internal departments.
Makes recommendations for fulfilment of basic to moderately complex benefit requests, including presenting these recommendations to PerformRx management and clients upon request.
Organizes and Documents benefit design specifications in a standardized, client-facing format for submission to the claims processing vendor.
Prepares test plans, scenarios, and executes manual and batch testing in User-Acceptance Testing and Production/Live Testing environments in the claims-processing software.
Monitors and reports claims activity based upon benefit set-up to ensure accurate processing according to the approved requirements from the client.
Troubleshoots reported claims defects and provides detailed summary of analysis and all available solutions for immediate mitigation with the claims-processor.
Processes claims transaction requests (rework).
Makes recommendations to management based upon trend analysis.
Reviews and writes comprehensive reports, identifies alternatives, and makes recommendations to management and clients, upon request.
Participation including leading of audits related to benefit or claims activity.
Performs other related duties and projects as assigned by the Managers or department Director as required.
Supports and carries out the PerformRx Mission & Values.
Adheres to all AmeriHealth Caritas and PerformRx policies and procedures.
Maintains a current knowledge base of PerformRx programs, services, policy and procedures.
Regularly reviews and adheres to standard operating guidelines, desktop procedures, checklists, templates, and memorandums issued to the department.
Creates and supports an environment which fosters teamwork, cooperation, respect and diversity.
Establishes and maintains positive communication and professional demeanor with PerformRx employees and customers at all times.
Demonstrates and supports commitment to corporate goals and objectives.
Bachelor’s degree preferred or equivalent work experience
Active/current CPhT certification (i.e., ExCPT, NCCT or PTCB) preferred
Minimum three (3) years of Pharmacy Benefit Manager (PBM), pharmacy operations, and/or healthcare/pharmacy claims processing experience required
Progressive and focused work experience in continuous improvement initiatives, project management, and/or organizational development
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