AmeriPharma
Claims Analyst
AmeriPharma, Laguna Woods, California, United States, 92637
About AmeriPharma
AmeriPharma is a rapidly growing healthcare company where you will have the opportunity to contribute to our joint success on a daily basis. We value new ideas, creativity, and productivity. We like people who are passionate about their roles and people who like to grow and change as the company evolves.
AmeriPharma's Benefits
Full benefits package including medical, dental, vision, life that fits your lifestyle and goalsGreat pay and general compensation structuresEmployee assistance program to assist with mental health, legal questions, financial counseling etc.Comprehensive PTO and sick leave options401k programPlenty of opportunities for growth and advancementCompany sponsored outings and team-building eventsCasual FridaysJob Summary
The Claims Analyst is responsible for performing routine auditing functions and providing comprehensive feedback on operational activities to ensure compliance with organizational policies and regulatory standards established by agencies such as CMS, DMHC, and DHS. This role involves various internal and external audit responsibilities, including routine audits, complex audits, and focused reviews. The Claims Analyst will identify exceptions to established claims adjudication requirements, ensuring accuracy in claims processing, payment, and adherence to procedural guidelines.
Schedule Details
On-Site Location: Laguna Hills, CAHours: Monday-Friday, 8:00 AM - 5:00 PMDuties and Responsibilities
Conduct thorough audits of pharmacy and medical claims, including routine, complex, and focused audits, to ensure compliance with internal policies and external regulations.Oversee and respond promptly to external payer audits, including determination appeals, refund requests, and overpayments, while ensuring compliance with regulatory requirements.Analyze Explanation of Benefits (EOB) statements and investigate cases involving beneficiaries, providers, and pharmacies for potential overpayments, fraud, waste, and abuse.Prepare comprehensive documentation, including inquiry letters, investigation findings, and case summaries, ensuring thorough records of all audit activities.Generate and report audit findings, procedural performance, and financial accuracy to management, highlighting trends and areas for improvement.Investigate and identify the root causes of claims discrepancies and process failures, providing actionable insights to relevant departments to enhance accuracy and efficiency.Contribute to the development of training materials and resources related to proper billing and coding.Continuously seek opportunities to enhance audit processes and claims workflows, implementing best practices to improve efficiency and effectiveness.Required Qualifications
Familiarity with Commercial, Medicare, and HMO business processes.Ability to interpret and apply Division of Financial Responsibility (DOFR) requirements.Knowledge of ICD-10, CPT-4, HCPCS, Revenue Codes, UB-04, and CMS-1500 forms.Strong understanding of claims billing, processing, terminology, diagnoses, and procedures.Strong analytical skills with the ability to evaluate and interpret information accurately.Capacity to work independently, exercise sound judgment, and manage time effectively.Education and Experience Requirements
Associate degree or equivalent required; further education in a related field is a plus.At least 2 years of experience in pharmacy and medical claims processing within health plan payors, PBM, MSOs, HMOs, or IPAs.A minimum of 1 year of experience in pharmacy and medical claims auditing.Required Skills
Strong experience in developing internal and external relationships/partnerships.Knowledge of pharmacy systems and workflows.Experience with pharmacy claims adjudication, claim rejections, and associated resolutions.Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint) and technical proficiency with databases and spreadsheets.Excellent written and verbal communication skills.Ability to interpret, adapt, and apply guidelines and procedures.Ability to establish and maintain effective working relationships with payors, staff, and coworkers.Demonstrates accuracy, strong analytical, and problem-solving skills.Actively seeks ways to improve quality and monitors personal work to ensure standards are met.Maintains confidentiality.Works independently, prioritizes activities, and uses time efficiently.Excellent interpersonal and customer service skills.Strong organizational skills and attention to detail.Exceptional time management skills with a proven ability to meet deadlines.Ability to prioritize tasks and delegate appropriately.Capacity to function effectively in a fast-paced and at times stressful environment.
AmeriPharma's Mission Statement
Our goal is to achieve superior clinical and economic outcomes while maintaining the utmost compassion and care for our patients. It is our joint and individual responsibility daily to demonstrate to outpatients, prescribers, colleagues, and others that We Care!
Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is continuously required to sit and talk or hear. The employee is occasionally required to stand; walk; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; and stoop, kneel, crouch or crawl. The employee must regularly lift and/or move up to 20 pounds and occasionally lift/or move up to 30 pounds. Specific vision abilities required by this job include close vision, peripheral vision, depth perception and the ability to adjust focus.
EEO Statement
The above statements are intended to describe the work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required. The duties and responsibilities of this position are subject to change and other duties may be assigned or removed at any time. AmeriPharma values diversity in its workforce and is proud to be an AAP/EEO employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, sexual orientation, gender identity, national origin, age, protected veteran status, or based on disability or any other legally protected class.
AmeriPharma is a rapidly growing healthcare company where you will have the opportunity to contribute to our joint success on a daily basis. We value new ideas, creativity, and productivity. We like people who are passionate about their roles and people who like to grow and change as the company evolves.
AmeriPharma's Benefits
Full benefits package including medical, dental, vision, life that fits your lifestyle and goalsGreat pay and general compensation structuresEmployee assistance program to assist with mental health, legal questions, financial counseling etc.Comprehensive PTO and sick leave options401k programPlenty of opportunities for growth and advancementCompany sponsored outings and team-building eventsCasual FridaysJob Summary
The Claims Analyst is responsible for performing routine auditing functions and providing comprehensive feedback on operational activities to ensure compliance with organizational policies and regulatory standards established by agencies such as CMS, DMHC, and DHS. This role involves various internal and external audit responsibilities, including routine audits, complex audits, and focused reviews. The Claims Analyst will identify exceptions to established claims adjudication requirements, ensuring accuracy in claims processing, payment, and adherence to procedural guidelines.
Schedule Details
On-Site Location: Laguna Hills, CAHours: Monday-Friday, 8:00 AM - 5:00 PMDuties and Responsibilities
Conduct thorough audits of pharmacy and medical claims, including routine, complex, and focused audits, to ensure compliance with internal policies and external regulations.Oversee and respond promptly to external payer audits, including determination appeals, refund requests, and overpayments, while ensuring compliance with regulatory requirements.Analyze Explanation of Benefits (EOB) statements and investigate cases involving beneficiaries, providers, and pharmacies for potential overpayments, fraud, waste, and abuse.Prepare comprehensive documentation, including inquiry letters, investigation findings, and case summaries, ensuring thorough records of all audit activities.Generate and report audit findings, procedural performance, and financial accuracy to management, highlighting trends and areas for improvement.Investigate and identify the root causes of claims discrepancies and process failures, providing actionable insights to relevant departments to enhance accuracy and efficiency.Contribute to the development of training materials and resources related to proper billing and coding.Continuously seek opportunities to enhance audit processes and claims workflows, implementing best practices to improve efficiency and effectiveness.Required Qualifications
Familiarity with Commercial, Medicare, and HMO business processes.Ability to interpret and apply Division of Financial Responsibility (DOFR) requirements.Knowledge of ICD-10, CPT-4, HCPCS, Revenue Codes, UB-04, and CMS-1500 forms.Strong understanding of claims billing, processing, terminology, diagnoses, and procedures.Strong analytical skills with the ability to evaluate and interpret information accurately.Capacity to work independently, exercise sound judgment, and manage time effectively.Education and Experience Requirements
Associate degree or equivalent required; further education in a related field is a plus.At least 2 years of experience in pharmacy and medical claims processing within health plan payors, PBM, MSOs, HMOs, or IPAs.A minimum of 1 year of experience in pharmacy and medical claims auditing.Required Skills
Strong experience in developing internal and external relationships/partnerships.Knowledge of pharmacy systems and workflows.Experience with pharmacy claims adjudication, claim rejections, and associated resolutions.Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint) and technical proficiency with databases and spreadsheets.Excellent written and verbal communication skills.Ability to interpret, adapt, and apply guidelines and procedures.Ability to establish and maintain effective working relationships with payors, staff, and coworkers.Demonstrates accuracy, strong analytical, and problem-solving skills.Actively seeks ways to improve quality and monitors personal work to ensure standards are met.Maintains confidentiality.Works independently, prioritizes activities, and uses time efficiently.Excellent interpersonal and customer service skills.Strong organizational skills and attention to detail.Exceptional time management skills with a proven ability to meet deadlines.Ability to prioritize tasks and delegate appropriately.Capacity to function effectively in a fast-paced and at times stressful environment.
AmeriPharma's Mission Statement
Our goal is to achieve superior clinical and economic outcomes while maintaining the utmost compassion and care for our patients. It is our joint and individual responsibility daily to demonstrate to outpatients, prescribers, colleagues, and others that We Care!
Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is continuously required to sit and talk or hear. The employee is occasionally required to stand; walk; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; and stoop, kneel, crouch or crawl. The employee must regularly lift and/or move up to 20 pounds and occasionally lift/or move up to 30 pounds. Specific vision abilities required by this job include close vision, peripheral vision, depth perception and the ability to adjust focus.
EEO Statement
The above statements are intended to describe the work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required. The duties and responsibilities of this position are subject to change and other duties may be assigned or removed at any time. AmeriPharma values diversity in its workforce and is proud to be an AAP/EEO employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, sexual orientation, gender identity, national origin, age, protected veteran status, or based on disability or any other legally protected class.