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Pharmacy/Billing Technician
American Health PartnersPharmacy Technician at American Health Plans responsible for claims adjudication operations. Collaborating with pharmacy teams and supporting Medicare Advantage Institutional Special Needs Plan processes.
About the role
Key responsibilities & impact- 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
What you’ll need- 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
Comp & perks- Equal Opportunity Employer
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
pharmacy claimsclaim rejectionsprior authorizationbilling requirementsformulary limitationsNCPDP reject codesclinical reportingdata documentationquality improvementclaims efficiency
Soft Skills
analytical skillscommunication skillspresentation skillscollaborationproblem-solvingprofessionalismorganizational skillsleadershiptime managementprocess improvement
Certifications
Pharmacy Technician CertificationCMS compliance trainingHIPAA trainingquality improvement trainingclaims processing certificationlong-term care certificationhealth plan certificationanalytical skills trainingcommunication skills trainingpresentation skills training