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.