Any office location or remote within WA, OR, UT, ID
The Clinical Review Pharmacy Analyst utilizes knowledge of drugs and pharmaceuticals to conduct post service audits to ensure accuracy of billed charges.
Prioritizes work, sets goals, and coordinates own activities to ensure that record reviews are performed so that timely audits can be performed according to the team's workflow.
Utilizes knowledge and experience to analyze billings to determine if charges are consistent with medical records, medical for drugs/pharmaceuticals and reimbursement policies. Identifies additional information needed and requests it when appropriate. May perform activities that require evaluation or interpretation of information related to drug administration and treatments.
Follows strict guidelines to ensure all work meets corporate standards for accuracy, timeliness, quality and compliance with federal, state, BCBSA and accreditation regulations. Organizes and keeps readily accessible all reference documents, policies and procedures needed to accomplish this.
Follows through on all assigned work; performs at a level meeting production requirements and quality standards.
Contributes to the efficiency of the department by being flexible and cross-trained on other functions.
Performs projects as requested by the supervisor.
Demonstrated competency in claim review and experience using billing and claims forms.
In-depth knowledge of drugs and pharmaceuticals to identify incorrectly billed medications, IV fluids and identify use of drugs for non-FDA approved treatments for investigational and off-label uses/administration.
Familiarity with health care documentation and effective oral and written communication skills.
Demonstrated initiative and strong problem-solving skills.
Demonstrated ability to consistently meet productivity and quality standards with minimal support.
Ability to work in fast-paced, multi-tasking, fluid environment with ever-changing priorities.
General computer skills (Microsoft Office, Outlook, Internet search).
Normally to be proficient in the competencies listed above
A Clinical Review Pharmacy Analyst would have a license/certification as a Pharmacy Technician and 2 years of experience in hospital or residential treatment facility and 3 years of health insurance claims experience or analytical experience or equivalent combination of education and experience. Payment review or coding experience is a plus.
Required Licenses, Certifications, Registration, Etc.
Licensed Pharmacy Technician
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.