Lumeris

Customer Support

• Reviews rejected pharmacy claims for appropriateness.
• Becomes a pharmacy claims processing subject matter expert and triages claims issues.
• Becomes subject expert with Medicare Part D policies and procedures.
• Reviews transition claims reports.
• Interacts with the pharmacy benefits manager, pharmacies, prescribers, and members to ensure appropriate and timely member access to prescription drugs.
• Supports medical pharmacy prior authorizations and Medicare Part D drug reconsiderations.
• Supports Medicare Part D call center questions and issues received from members, pharmacies, and providers.
• Supports compliance functions and requests.
• Supports quality programs including STARS.
• Conducts retrospective claims reviews.
• Complies, interprets, documents, and tracks findings from claims monitoring data.

Pharmacy Operations Support Specialist

Actuary

• Model & Tool Development
• Design, build, and validate actuarial and analytic models from the ground up
• Develop efficient processes to support business operations, financial reporting, and MA PD bids
• Formalize and adhere to team standards for model design and work quality
• Continuously refine and improve models based on emerging data and business needs
• One-Off & Strategic Analytics
• Perform deep-dive, ad hoc analyses to answer complex business questions, displaying high degrees of mathematical rigor and common sense
• Translate ambiguous business problems into structured analytical methodologies
• Present findings clearly to both technical and non-technical stakeholders to influence business decisions
• Own and manage analytic projects from planning to communication of results.

Senior Actuarial Analyst

Financial Planning and Analysis

• Oversee the day-to-day operations of the AP and AR/Premium Billing functions.
• Manage and develop a team, providing guidance, training, and performance feedback to ensure departmental goals are met.
• Oversee all accounts payable processes, including vendor invoice processing, provider claims payment processing, and commission payments, ensuring accuracy and timeliness.
• Drive enhancements to the AP/invoicing platform to increase efficiency and improve the customer experience.
• Own and manage the entire member/group premium billing cycle, including invoicing, collections, cash posting, and reconciliations.
• Oversee the application of payments from various sources (lockbox, EFT, member portal), ensuring accuracy and timeliness.
• Manage the collections process for outstanding receivables, including the relationship with the collection agency.
• Handle correspondence, premium refunds, and adjustments as necessary.
• Partner with third-party print/mail and payment portal vendors to enhance the customer experience and resolve issues.
• Identify opportunities for process improvements and workflow automation within the AP and AR cycles.
• Serve as the business lead for system enhancements, including performing User Acceptance Testing (UAT).
• Ensure compliance with all relevant regulations, including CMS, State DOI, and HIPAA.
• Serve as the subject matter expert and business owner for all audits (Financial, SOX, State, Federal) related to AP and AR/Premium Billing, including managing evidence requests.

Pharmacy Operations Support Specialist

Senior Actuarial Analyst

Manager, Health Plan Finance Operations