A Pharmacy Claims Specialist is responsible for leading, acting as a technical resource, and developing requirements for pharmacy claims, and accumulator-related projects. Essential functions are listed on the Pharmacy Claims Specialist Resume as – communicating directly with providers to solve claims and accumulator issues, reviewing claims scan outputs and potential issues from the third-party auditor, performing claims root cause analysis, performing oversight functions for pharmacy accumulator processing and issues, submitting and monitoring claims and accumulator issues/tickets; providing recommendations for changes to claims payments, and creating process flow, policies, and procedures.
Hiring employers typically prefer to hire those possessing the following skills and abilities – experience with pharmacy claims billing, auditing, and claims issue resolutions; experience in claims adjunction system analysis and solution development; training skills, and knowledge of pharmacy claims terminology, billing practice, and adjudication processes. A bachelor’s degree and work experience are required.
Objective : Dedicated Pharmacy Claims Specialist with 2 years of experience in processing and managing pharmacy claims. Proficient in utilizing claims systems and ensuring compliance with healthcare regulations. Committed to delivering exceptional customer service while accurately handling sensitive patient information. Aiming to leverage my expertise to enhance operational efficiency in a dynamic healthcare environment.
Processed insurance claims using advanced claims management software, ensuring accuracy and compliance.
Interpreted claims status for providers and patients, providing clear guidance on processes and requirements.
Educated members on prescription benefits and cost-saving alternatives, enhancing customer satisfaction.
Ensured timely processing of medication claims to facilitate patient access to necessary treatments.
Maintained confidentiality and compliance with HIPAA regulations while handling sensitive patient information.
Collaborated with healthcare providers to verify patient eligibility and resolve claims discrepancies.
Monitored and troubleshot rejected claims, implementing solutions for correct payment outcomes.
Experience
0-2 Years
Level
Entry Level
Education
AAS Pharmacy
Junior Pharmacy Claims Specialist Resume
Objective : Motivated pharmacy claims professional with 5 years of experience in claims processing and patient support. Skilled in navigating complex claims systems and ensuring adherence to healthcare regulations. Committed to providing exceptional service while safeguarding patient confidentiality. Eager to utilize my expertise to enhance operational workflows and improve patient outcomes in a dynamic pharmacy environment.
Skills : Claims Management Software, Claims Processing Systems, Pharmacy Benefit Management, Data Analysis, Medical Records Management
Description :
Reviewed and processed pharmacy claims, ensuring accuracy and compliance with regulations.
Resolved complex claim issues by determining correct payment or denial amounts and documenting processes.
Delivered exceptional customer service to physicians and patients, addressing inquiries promptly.
Assisted members with pharmacy-related questions and troubleshooting issues with claims systems.
Maintained patient confidentiality while processing sensitive information.
Collaborated with healthcare providers to confirm patient insurance coverage and eligibility.
Utilized data analysis to identify trends in claims submissions and improve processing efficiency.
Experience
2-5 Years
Level
Junior
Education
AAS in Pharmacy Tech
Pharmacy Claims Specialist Resume
Headline : Seasoned Pharmacy Claims Specialist with 7 years of expertise in claims processing and resolution. Proficient in interpreting and applying healthcare regulations while ensuring compliance and accuracy. Passionate about enhancing patient care through effective claims management, and dedicated to optimizing operational workflows for improved service delivery.
Mentored pharmacy claims specialists to foster professional growth and improve team performance.
Identified and addressed reasons for claim rejections, implementing corrective actions to minimize denials.
Managed multiple sensitive projects simultaneously while prioritizing workload effectively.
Generated weekly reports detailing team performance, challenges, and solutions for management review.
Utilized various claims processing applications to enhance efficiency and accuracy.
Conducted training sessions to elevate team knowledge on claims processing best practices.
Collaborated with cross-functional teams to ensure seamless claims processing and patient support.
Experience
5-7 Years
Level
Senior
Education
B.S. Health Admin.
Lead Pharmacy Claims Specialist Resume
Summary : Accomplished Lead Pharmacy Claims Specialist with 10 years of extensive experience in managing and optimizing pharmacy claims processes. Adept at ensuring compliance with healthcare regulations and enhancing patient experiences through effective claims resolution. Looking to leverage my expertise to lead teams in delivering exceptional service and operational excellence in a fast-paced environment.
Skills : Regulatory Compliance, Pharmacy Software, Attention To Detail, Problem Solving, Analytical Skills, Time Management
Description :
Adjudicated pharmacy claims efficiently, ensuring compliance with healthcare regulations and enhancing customer satisfaction.
Conducted thorough investigations and resolved claim rejections by identifying root causes and implementing corrective actions.
Utilized critical thinking skills to interpret complex claims data and deliver timely resolutions.
Processed over 25 claims per hour with an error rate of only 0.07%, exceeding departmental benchmarks.
Adapted to procedural changes swiftly while maintaining high standards of accuracy and productivity.
Identified alternative medication options to ensure claims were processed accurately and efficiently.
Facilitated effective communication with stakeholders to present information clearly in both individual and group settings.
Experience
7-10 Years
Level
Management
Education
B.S. Pharmacy
Pharmacy Claims Specialist Resume
Summary : With a decade of experience as a Pharmacy Claims Specialist, I excel in processing and managing complex pharmacy claims while ensuring compliance with healthcare regulations. My strong analytical skills and commitment to patient care enable me to resolve issues efficiently, enhancing operational workflows and delivering outstanding service in dynamic pharmacy environments.
Processed a high volume of pharmacy claims accurately, utilizing advanced claims management software and ensuring compliance with regulatory standards.
Collaborated with insurance representatives to clarify eligibility and resolve billing discrepancies.
Analyzed claim rejections and coding issues, implementing corrective actions to ensure patients receive prescribed medications.
Consistently met quality and timeline objectives by optimizing workflows and prioritizing tasks effectively.
Provided exceptional customer service by responding to patient inquiries and assisting with prescription intake processes.
Conducted audits of claims submissions to identify areas for improvement and enhance operational efficiency.
Maintained accurate records and documentation, ensuring alignment with healthcare regulations and company policies.
Experience
10+ Years
Level
Executive
Education
B.S. Pharmacy
Junior Pharmacy Claims Specialist Resume
Objective : Proficient Junior Pharmacy Claims Specialist with 5 years of experience in processing and managing pharmacy claims. Expertise in navigating complex claims systems and ensuring adherence to healthcare regulations. Focused on delivering outstanding customer service while safeguarding sensitive patient information. Excited to apply my skills to improve operational efficiency in a fast-paced pharmacy environment.
Skills : Customer Relationship, Team Collaboration, Adaptability, Critical Thinking
Description :
Review and process pharmacy claims for accuracy and compliance with regulations.
Ensured compliance with Board of Pharmacy and HIPAA regulations during claims processing.
Troubleshot rejected claims to identify issues and implement corrective actions.
Reported systematic issues to management to enhance claims processing efficiency.
Proactively updated knowledge on evolving company policies and procedures.
Consistently met department deadlines, ensuring high-quality customer service.
Collaborated with team members to enhance operational workflows and service delivery.
Experience
2-5 Years
Level
Junior
Education
B.S. Health Admin.
Pharmacy Claims Specialist Resume
Objective : A results-oriented Pharmacy Claims Specialist with 2 years of experience in processing pharmacy claims and ensuring compliance with healthcare regulations. Adept at resolving claim issues and optimizing workflows to enhance patient service. Eager to contribute my skills in a collaborative environment to improve operational efficiency and support patient care.
Skills : Billing Codes Knowledge, Data Management, Reimbursement Knowledge, Pharmacy Operations, Training And Mentoring, Process Improvement
Description :
Ensured compliance with company protocols in third-party insurance adjudication processes.
Conducted thorough research and processed claims payment adjustments based on customer service referrals and audits.
Streamlined claims processing workflows to enhance efficiency and service delivery.
Utilized analytical skills to identify and resolve discrepancies in claims submissions.
Collaborated with healthcare providers to verify patient information and insurance benefits.
Maintained meticulous records of claims and adjustments for audit purposes.
Provided exceptional customer support, addressing inquiries and resolving issues promptly.
Experience
0-2 Years
Level
Entry Level
Education
AAS-Pharm Tech
Senior Pharmacy Claims Specialist Resume
Headline : Detail-oriented Pharmacy Claims Specialist with over 5 years of experience in processing and adjudicating pharmacy claims. Proficient in analyzing claims data, resolving discrepancies, and ensuring compliance with regulatory standards. Strong communication skills and a commitment to providing exceptional customer service. Adept at collaborating with healthcare providers and insurance companies to optimize claim outcomes.
Skills : Data Entry, Customer Service, Medical Terminology, Claims Adjudication, Multi-tasking, Research Skills
Description :
Processed and adjudicated pharmacy claims accurately and efficiently to ensure timely reimbursements.
Resolved billing discrepancies and adjudication issues, improving claims resolution rates.
Ensured compliance with healthcare regulations, maintaining accurate and complete records.
Investigated and verified missing or incorrect information, enhancing claim accuracy.
Facilitated communication among patients, healthcare providers, and insurance companies to resolve claims issues.
Verified insurance eligibility and benefits, optimizing patient access to medications.
Managed incoming inquiries from members, providing guidance and support on claims-related matters.
Experience
5-7 Years
Level
Senior
Education
B.S. Pharmacy
Pharmacy Claims Specialist Resume
Objective : Results-driven Pharmacy Claims Specialist with 5 years of experience in processing and resolving pharmacy claims. Well-versed in regulatory compliance and adept at optimizing claims workflows. Committed to maintaining patient confidentiality while delivering superior customer service. Excited to leverage my skills to enhance operational performance in a fast-paced healthcare environment.
Skills : Cost Containment, System Integration, Database Management, Inventory Control, Ehr Systems, Hipaa Compliance
Description :
Processed and adjudicated prescription insurance claims using advanced claims management software.
Conducted thorough reviews of rejected claims to identify and resolve discrepancies.
Collaborated with insurance carriers and healthcare providers to obtain necessary claims information.
Verified patient and prescription details to facilitate efficient claims adjudication.
Determined appropriate claims payments or denials while escalating complex issues to management.
Maintained high ethical standards in interpreting claims data and contracts.
Provided support for Humana Medicare members through effective communication and problem-solving.
Experience
2-5 Years
Level
Junior
Education
B.S. Health Admin.
Pharmacy Claims Specialist Resume
Summary : Accomplished Pharmacy Claims Specialist with a decade of experience in managing pharmacy claims processing and ensuring regulatory compliance. Expert in utilizing advanced claims systems to enhance operational efficiency and resolve complex issues. Passionate about driving patient satisfaction and improving workflows, I am eager to contribute my extensive knowledge in a fast-paced healthcare environment.
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