Under the direction of a Supervisor, the Representative in PFM Business Intelligence is a member of the Business Intelligence team and is responsible for auditing contract and MAC exceptions and supporting client initiatives. Duties include identifying MAC, pricing and contract exceptions, submitting appeals to the carriers, recording responses from the carriers, preparing standard reporting, interacting with numerous internal and external parties, cross-training with other team members, pulling data and adding MAC appeals information for QBRs and MBRs, product testing and uploading claims and tagging in the Audit Management Application.
Primary Accountabilities:
Analytical
Understand the nature of retail pharmacy
Monitor the data to ensure that the carriers adjusted reimbursement
Run reports and create uploads to vet and submit claims for MAC appeals
Create and deliver standard MAC reporting on a weekly basis to the client
Technical
Use data visualizations appropriately and effectively
Identify, develop and implement new procedures to increase efficiency and productivity of work processes
Participate in product grooming, perform and lead user acceptance testing
Produce reports and other requested deliverables including financial analysis
Design internal and external facing dashboards for trending and benchmarking
Operational
Contact clients for invoices when needed; fax invoices and supporting documentation to the carriers
Run reports and create uploads to vet and submit claims for MAC appeals
Upload claims in the Audit Management App
Tag claims for Audits in the Pharmacy Management tool
Pursue MAC appeals and Contract exceptions using the Contract Management App and Business Intelligence tools
Follow documented best practices for submitting MAC and Contract exceptions to the carriers
Participate in agile missions to improve processes
Support the Product teams in relation to product enhancements:Identifying product enhancements that would be beneficial for clients
Performing user acceptance testing on product enhancements
Administrative
Pull data for Quarterly Business Reviews and Monthly Business Reviews
Pull data for ad hoc analysis
Record the responses from the carriers, potential savings and cost adjustments in the application
Keep abreast of state level MAC legislation
Follow up with the carriers after submitting appeals in a timely manner
Continue to update MAC Appeals forms, spreadsheets, procedures, etc in the MAC Google Drive site
Share MAC results with the team
Maintain HIPAA (Health Insurance Portability and Accountability Act) compliance in all client communication
Perform special projects and other duties as assigned by management
Additional Responsibilities:
Required Qualifications:
1-3 years At least 2 years of relevant experience involving customer service, computer usage, data entry and data analysis AND an Associate’s degree in Business Administration, Accounting, or a related field; OR an equivalent combination of training and experience required to complete the essential functions/job responsibilities of the position required
Proficient in Microsoft Office Suite, Microsoft Windows
Competent in 10 Key Manual Entry, Google Office Suite
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We are an Equal Opportunity Employer, including disability/vets.
