You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking a detail-oriented and experienced Pharmacy Benefit Management (PBM) Billing Specialist to join their team. The specialist will be responsible for ensuring the accurate and timely processing of pharmacy benefit claims, verifying eligibility, managing prior authorizations, and addressing billing discrepancies. This role involves working closely with both payers and patients to ensure correct claim adjudication, resolve issues, and maintain a high level of customer service. The specialist will play a key role in ensuring compliance with all billing regulations while meeting company standards for accuracy and efficiency.
Responsibilities / Job Duties
- Determine proper financial/coverage risk.
- Process claims via electronic billing adjudication systems.
- Work through payable claim responses.
- Resolve claim rejections.
- Manage prior authorization process, including responding to deferrals and handling delegated appeals.
- Address secondary billing needs and understand the transfer of coverage benefits and retroactive eligibility.
- Collect patient payments.
- Maintain compliance with timely billing and follow-up requirements for all claims.
- Demonstrate expertise in successful claim adjudication and resolve issues efficiently.
- Tag delivery tickets and rebill with necessary corrections.
- Ensure all RxB billing processes meet company standards for accuracy and timeliness.
Minimum Education and Experience Qualification Requirements
Qualifications
- Minimum of 2 years of experience as a pharmacy or medical biller, and/or collector.
- Strong knowledge of PBM operations, A/R management, and claims processes.
- Pharmacy claims adjudication experience, or experience in collections, A/R, and appeals.
- Knowledge of the Prior Authorization process (submission, deferral, and appeals).
- Familiarity with medical terminology.
- Knowledge of proper billing/CMS guidelines.
- Strong understanding of insurance eligibility, including Medicare (A-D), government, commercial, pharmacy plans, and coverage gap knowledge.
- Proficiency in ICD-10 coding and understanding of pharmacy coding (NDC).
- Experience with standard billing formats (HCFA 1500, UB04, UCF, 30-1, 30-4).
- Specialized claims pricing experience (AWP, UC, GER, BER).
- Familiarity with MS Word, Excel, Outlook, and EMR systems.
Schedule / Shift
Monday to Friday, 10:00 AM – 7:00 PM and rotating Saturdays (9:00 AM – 5:30 PM; currently once every 5 weeks).
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
