The key words are "Benefit configuration in a claims processor".
They will be mapping rules in Platform A over to Platform B and doing the QA to ensure the claims adjudicate properly including Custom rules, overrides and prior authorization requirements.
? Manages assigned tickets within a ticketing system; troubleshoots and resolves tickets that
are placed in the Adjudication queues in a timely manner
? Adjudicates benefits for clients on multiple software platforms. Follows outlined Standard
Operating Procedure (SOP) and Desk Top Procedures (DTP) documents for implementing
new clients and existing programs, client creation in claims processor, client and program
terminations
? Enforces procedures that are put in place by the Director, Sr Manager, and Supervisor of
Adjudication in addition to Senior Leadership
? Assists with claim research for internal and external programs
? Assists with executing Pharmacy Network set ups and list management within the claims
processors
? Communicates with the Implementation team to discuss and/or ask questions regarding
benefit designs for onboarding clients
? Helps with ad hoc projects surrounding Adjudication systems and ticketing queue
? Communicates with the EDI team to discuss and/or ask questions regarding various data
files
? Communicates with the Clinical team to discuss and/or ask questions regarding clinical
edits for current and existing clients
? Communicates with the Client Experience team to discuss and/or ask questions regarding
the plan design for current clients, clarify client intent, and ensure correct documentation is
captured to align claims process and requested client benefit set up
? Pulls reporting to assist with migration of clients from external claims processor to internal
claims processor
? Assists with providing permissions within internal claims processor to internal and external
team members, clients, Third Party Administrators, and brokers
? Assists with quality standards from an objective point of view and provides input, when
appropriate to further ensure the proper checks and balances are applied to all parts of the
Adjudication procedures
? Works with Controls and Quality Assurance team to assure benefit design quality for all
clients, when applicable
? Abides by all obligations under HIPAA related to Protected Health Information (PHI)
? If a HIPAA violation is discovered, whether individually or by another, reports the violation to
the Compliance Officer and/or Human Resources
? Attends, completes, and demonstrates competency in all required HIPAA Training offered
by the company
? Flexibility to understand, appreciate and embrace that the job description is not designed to
cover or contain a comprehensive listing of activities, duties or responsibilities that are
required of the employee.
Role and Responsibilities
? Manages assigned tickets within a ticketing system; troubleshoots and resolves tickets that
are placed in the Adjudication queues in a timely manner
? Adjudicates benefits for clients on multiple software platforms. Follows outlined Standard
Operating Procedure (SOP) and Desk Top Procedures (DTP) documents for implementing
new clients and existing programs, client creation in claims processor, client and program
terminations
? Enforces procedures that are put in place by the Director, Sr Manager, and Supervisor of
Adjudication in addition to Senior Leadership
? Assists with claim research for internal and external programs
? Assists with executing Pharmacy Network set ups and list management within the claims
processors
? Communicates with the Implementation team to discuss and/or ask questions regarding
benefit designs for onboarding clients
? Helps with ad hoc projects surrounding Adjudication systems and ticketing queue
? Communicates with the EDI team to discuss and/or ask questions regarding various data
files
? Communicates with the Clinical team to discuss and/or ask questions regarding clinical
edits for current and existing clients
? Communicates with the Client Experience team to discuss and/or ask questions regarding
the plan design for current clients, clarify client intent, and ensure correct documentation is
captured to align claims process and requested client benefit set up
? Pulls reporting to assist with migration of clients from external claims processor to internal
claims processor
? Assists with providing permissions within internal claims processor to internal and external
team members, clients, Third Party Administrators, and brokers
? Assists with quality standards from an objective point of view and provides input, when
appropriate to further ensure the proper checks and balances are applied to all parts of the
Adjudication procedures
? Works with Controls and Quality Assurance team to assure benefit design quality for all
clients, when applicable
? Abides by all obligations under HIPAA related to Protected Health Information (PHI)
? If a HIPAA violation is discovered, whether individually or by another, reports the violation to
the Compliance Officer and/or Human Resources
? Attends, completes, and demonstrates competency in all required HIPAA Training offered
by the company
? Flexibility to understand, appreciate and embrace that the job description is not designed to
cover or contain a comprehensive listing of activities, duties or responsibilities that are
required of the employee.
Qualifications
? 2+ years' previous experience working in PBM environment and using a claims processor
in a benefit design or configuration capacity
? Intermediate or advanced proficiency with MS Excel, Word, PowerPoint, Outlook
? Excellent verbal and written communication skills, establishing rapport and working with
others
? Organization
? Time Management
? Strong Problem-Solving Skills
? Strong communication/collaboration skills
? Easily adapt to and learn new technology and skills
? Thoroughness
software platforms,data files,ticketing system,MS Excel,Outlook,PowerPoint,Word,Easily adapt,Thoroughness,Excellent verbal and written communication,communication,Leadership,Strong Problem-Solving Skills,Adjudication,Clinical,Client Experience,HIPAA Training,HIPAA,Human Resources,innovative,claims,collaboration skills,Protected Health Information,quality standards,Quality Assurance,Standard Operating Procedure,Time Management
Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.
At Randstad Digital, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact
Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad Digital offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).
This posting is open for thirty (30) days.
