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.
Headline : Motivated professional with a wide range of skills in the areas of public safety and a corporate environment. Experienced includes a quality-driven focus towards adapting to company strategies and goals, strive to excel at any task given, and enhance leadership qualities.
Skills : Microsoft Office, Bookkeeping, Customer Service, Data Entry.
Description :
Processed prescription insurance claims using a combination of off the shelf and customized computer-based applications.
Verified patient, prescription and third-party payer information to ensure efficient, effective and valid claims adjudication.
Assured that all third party (insurance) adjudication processes are completed in accordance with company protocol.
Reviewed and investigated all rejected claims to identify issues and solutions.
Called insurance carriers, physicians' offices and patients to acquire additional claims information.
Determined correct claims payment or denial for reimbursement.
Identified and elevated questionable claims, authorizations, or system issues to the proper management authority as appropriate.
Experience
5-7 Years
Level
Executive
Education
GED
Pharmacy Claims Specialist Resume
Objective : To establish a long-term career in a company where I may utilize my Pharmacy Claims Specialist professional skills and knowledge to be an effective Associate Program Manager and inspiration to those around me.
Skills : Microsoft PowerPoint, Navinet, CPR+, Research, MRO, Counseling.
Description :
Reviewed electronic claims and processing additional data into the claims system as necessary.
Resolved computer-generated edit conditions, determining correct payment or denial amounts and documenting the appropriate process.
Investigated health plan prescription claim rejections/denials, coding and other issues that could result in a patient not receiving their medication as prescribed.
Provided and maintained highest levels of customer service to physicians and their patients.
Assisted members with pharmacy questions and help troubleshoot issues with ARGUS.
Assisted members with making premium payments through online billing.
Assisted members with pharmacy questions and help troubleshoot issues with ARGUS.
Experience
0-2 Years
Level
Entry Level
Education
Bachelor Of Sciences
Pharmacy Claims Specialist Resume
Headline : Twenty Five years of strong management and leadership experience in a variety of settings in both the public and private sectors. Successfully demonstrated organizational, interpersonal, leadership, management, and technical skills in all areas.
Skills : Microsoft Office, Medical Terminology, Scheduling, Computer , Call Center, Operations Management, Military.
Description :
Adjudicated complex reimbursement and insurance benefit investigations.
Motivated, mentored and developed Pharmacy claims specialists to encourage growth and high performance.
Properly identified reasons for rejections and institute corrective action to reduce the overall incidence of prescription denial.
Prioritized workload and managed multiple sensitive issues and projects at once.
Provided end of the week reports, detail frequent problems, team accomplishments, queue volumes, team morale, and additional requirements as needed.
Experienced with various applications.
Experience
5-7 Years
Level
Executive
Education
GED
Pharmacy Claims Specialist Resume
Headline : Highly organized and detail-oriented professional with over 5 years' experience as a Senior Representative, serving as a mentor as well as a Subject Matter Expert. Project management experience within a professional environment, successfully managing small to large projects from start to finish.
Skills : Outlook, Pharmacist.
Description :
Adjudicated claims that have been submitted by either the patient or the prescribing physician, to ensure that the customer experience is of the highest quality.
Researched, investigated, troubleshoot, and resolved the root cause of assigned claim rejections due to various edits.
Incorporated critical thinking and reasoning ability to apply common sense understanding to carry out instructions or time-sensitive program changes furnished in written, oral, or diagram form.
Processed 25+ orders per hour with a .07% error rate, which exceeds the pharmacy expectations of 11 orders per hour.
Ability to implement procedural changes within a moment's notice without endangering the integrity of the pharmacy orders while maintaining productivity and quality standards.
Identified alternative drug choices as needed to ensure that the transaction is processed completely, correctly, and efficiently.
Effectively presented information in one-on-one and small group situations to customers, clients, employees, and management of the organization.
Experience
5-7 Years
Level
Executive
Education
MS
Pharmacy Claims Specialist Resume
Objective : Pharmacy Claims Specialist offering extensive experience in medical terminology and customer support within insurance and pharmaceutical settings. Adept in gathering and recording time-sensitive information accurately and according to established protocols. Highly capable and self-motivated, quickly developing product and procedural knowledge.
Skills : Therapist, MS Office.
Description :
Processed a high volume of insurance claims using active listening skills and proprietary software applications on behalf of this pharmacy dispensing service that also provides insurance reimbursement support and customer service to patients and physicians nationwide.
Verified patient, prescription and third-party payer information to ensure efficient, valid claims adjudication.
Corresponded with insurance representatives to determine eligibility, plan limitations and appropriate claims billing.
Researched health plan prescription claim rejections/denials and coding issues that could result in patients not receiving medications as prescribed.
Continually met all quality and timeline objectives.
Professionally and compassionately responded to a high volume of patient calls regarding prescription medications; gathered personal health and demographic data.
Delivered exceptional customer service while performing prescription intakes, and as a call center representative.
Experience
2-5 Years
Level
Executive
Education
MS
Pharmacy Claims Specialist Resume
Headline : Attended school to fulfill the desire of entering a Business related field where my goal is to become a CPA. Knowledge of Microsoft products (i.e. Word, Excel, PowerPoint) Excellent typing skills Learned teamwork by participating in many team skill-building projects Take charge when it is called for and able to work in pressured situations including time sensitive projects.
Skills : Adobe Illustrator, Adobe Photoshop.
Description :
Contacted insurance carriers to verify patient eligibility.
Reviewed and processed insurance claims and prescriptions.
Ensured that adjudication processes are complete within the parameters of the Board of Pharmacy and HIPPA.
Troubleshoot rejected claims to detect issues and ensure solutions for correct payment or denial amount.
Reported systematic issues or problematic claims to appropriate management as needed.
Taken initiative to stay up to date on evolving company policies and procedures.
Met department deadlines to ensure exceptional customer service is provided.
Experience
5-7 Years
Level
Executive
Education
High School Diploma
Pharmacy Claims Specialist Resume
Headline : To obtain a Pharmacy Claims Specialist position in your company that utilizes my skills, work ethic, achievements and no-nonsense negotiating abilities.
Processed prescription insurance claims using a combination of off the shelf and customized computer-based applications.
Verified patient, prescription and third party payer information to ensure efficient, effective and valid claims adjudication.
Ensured that all third party (insurance) adjudication processes are completed in accordance with company protocol.
Reviewed and investigated all rejected claims to identify issues and solutions.
Called insurance carriers, physicians' offices and patients to acquire additional claims information.
Determined correct payment or denial amounts and documents the appropriate process.
Researched and processed claims payment adjustments as a result of customer service referrals, audits, or data inaccuracies.
Experience
5-7 Years
Level
Executive
Education
Diploma In Medical
Pharmacy Claims Specialist Resume
Objective : Experienced in cleaning, mopping, sweeping and vacuuming commercial office buildings through self employed franchise with Vanguard cleaning systems. Excellent interpersonal skills from years in the healthcare environment. Very flexible and dependable to work in the evenings and extremely hard working.
Provided accurate and reliable prescription claims.
Resolved billing errors, adjudication issues and reconciliations.
Ensured all relevant data is complete and accurate.
Verified, investigated, and resolved any missing information or details.
Provided continuous communication between patients, health centers, insurance carriers, and PBM providers.
Verified pharmacy insurance eligibility, benefits, and patient share of cost for certain medications with 3rd party and governmental payers upon scheduling of patients.
Answered incoming calls for United Health Care Medicare members.
Experience
2-5 Years
Level
Junior
Education
Associate's
Pharmacy Claims Specialist Resume
Headline : Energetic motivated Pharmacy Claims Specialist professional with experience in all kinds of fields. Driven professional who is reliable, compassionate and a fast learner. Proven contributor who is looking to deliver excellent services, and maintain progressive relationships with clients.
Skills : Microsoft Office, Patient Care.
Description :
Processed prescription insurance claims using a combination of off the shelf and customized computer-based application.
Processed prescription insurance claims using computer based applications.
Reviewed and investigated all rejected claims to identify issues and solutions Called insurance carriers, physician offices and patients to acquire additional claims information.
Verified patient, prescription and third party payer information to ensure efficient and effective claims to adjudicate.
Determined correct claims payment or denial for reimbursement Identifying and elevating questionable claims, authorizations, or system issues to the proper management authority as appropriate.
Exercised the highest level of professional ethics in interpreting prescription claims data and contracts.
Answered incoming calls for Humana Medicare members.
Experience
5-7 Years
Level
Executive
Education
Certificate In Clinical Medical Assistant
Pharmacy Claims Specialist Resume
Objective : Multifaceted, efficient, reliable administrative and service professional with 10+ years of experience supporting managers and customers to improve internal operations including exceeding claims processing and call quotas. Proficient using standard office desktop software, CRM applications, design programs and proprietary business solutions software. Demonstrated skills in teamwork, professionalism in all communication and completing assigned tasks.
Skills : Pharmacy Technician, Planning Skills.
Description :
Claims Processed Help Desk through Microsoft CRM Dynamics application, Pharmacy Claim Adjudication and Audit Response.
Directed and coordinated operations for California based network pharmacy Oversaw pharmacy claim quality control, identifying and resolving procedural flaws to continue improvement of employees in a startup company.
Responsible for oversight, implementation and execution of the autorefill campaign program.
Processed claims to contribute to 15,000 Prescriptions processed daily while operating below a departmental baseline of 3% error rate.
Operated under HIPPA guidelines and held to the highest standards regarding patient confidentiality.
Reconciled coding and other issues that could result in a patient not receiving their medication as prescribed and instituted corrective action to reduce the overall incidence of prescription denial.
Included processing complex reimbursement and insurance benefit investigations.
Creating an account is free and takes five seconds.
You'll get access to the PDF version of this resume template.
Choose an option.
Sign up with Google
Sign up with Facebook
Sign up with Linkedin
This helps us make sure you're human and prevents spammers from abusing our services.
By continuing, you agree to our Privacy Policy and Terms.
Unlock the Power of Over 10,000 Resume Samples.
Take your job search to the next level with our extensive collection of 10,000+ resume samples. Find inspiration for your own resume and gain a competitive edge in your job search.
Get Hired Faster with Resume Assistant.
Make your resume shine with our Resume Assistant. You'll receive a real-time score as you edit, helping you to optimize your skills, experience, and achievements for the role you want.
Get Noticed with Resume Templates that Beat the ATS.
Get past the resume screeners with ease using our optimized templates. Our professional designs are tailored to beat the ATS and help you land your dream job.
