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  • La Grange, KY

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Pharmacy Customer Service and Compliance Specialist

Rawlings Group • La Grange, KY

Posted 6 days ago

Job Snapshot

Travel - None
Experience - At least 1 year(s)
Degree - High School
Insurance, Healthcare - Health Services, Managed Care
Insurance, Health Care, Customer Service

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Job Description

Are you someone who enjoys working in a fast paced office setting, using multiple information systems and communication methods to investigate and resolve health insurance claim related matters?  If so, we have a job for you! 

The Rawlings group, founded in 1977, is the premier leader in payment integrity services to the health insurance industry.  Located in La Grange, KY, The Rawlings Group employs over 1,400 people and is growing.  If you are looking for a great opportunity to make positive impact on the future of healthcare, The Rawlings Group needs to be your career choice.

We are looking for someone with a strong detail orientation, who enjoys researching insurance claim information to join our Medicare Validation and Compliance department.  Training will be provided.  This is a great opportunity for someone who has worked in customer service. 

The person selected will verify potential other party liability information by reaching out by phone or email, and working with insurance carriers, attorneys, case administrators, employers and/or members.  They will determine if accident or injury cases are valid and if there is a viable source of recovery. For valid and recoverable cases, they will also investigate paid drug claims for members involved to determine if they were related to the specific injury, and if so place the responsible party on notice.  The services completed will directly support our client’s Medicare Part D Compliance Program.

Job Requirements

Essential Duties and Responsibilities:

  • Verify CMS information including accident type, date of accident, accident details, patient injuries, sources of recovery, and status of any claim made by the patient.
  • Document all updated information in both Pharmacy (RxSelect) and Subrogation (SRS) systems.
  • Determine if the case is valid.  Follow appropriate steps for invalid and valid cases.
  • Follow specific process to determine if paid pharmacy claims are related to the specific case for valid and recoverable cases and place responsible party on notice.
  • Manage a caseload of 600-800 investigations, completing 300-400 per month.
  • Follow specific time frames to complete the validation.
  • The ability to work at our Facility and maintain our regular work schedule of Monday through Friday, 8:00 am- 5:00 pm.

Skills and Abilities:

  • Excellent attention to detail and organizational skills.
  • Good communication skills both verbally and written, including excellent phone communication skills.
  • Ability to work well in a fast paced, high volume environment.
  • A proven record of being dependable and reliable.
  • Strong skills in Microsoft Office programs.

Experience Requirements;

  • 1+ years working in a position that includes frequent inbound and/or outbound phone work.
  • 1+ years experience in a past paced, high volume environment preferred.
  • Experience working with detailed information. 

Education Requirements:

  • High school diploma or equivalent
  • Associate’s Degree preferred.
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