Description

Become a part of our caring community
As a Senior Pharmacy Claims Professional, you will serve as a subject matter expert for pharmacy within the Wisconsin market, supporting the WI FIDE SNP and Medicaid OTC programs. You will be responsible for researching pharmacy claims, resolving complex pharmacy-related issues, and collaborating closely with care management teams. Reporting to the Associate Director, FCP Clinical and Pharmacy, you will work with Humana Pharmacy Solutions and CenterWell to ensure member needs are met efficiently and effectively. You will contribute to process improvements, uphold compliance with regulatory standards, and act as a strategic resource for the Wisconsin market. Leveraging your expertise, you research and resolve pharmacy inquiries, partner with care management and pharmacy teams to address member concerns and influence departmental strategies. You are empowered to make independent decisions on complex issues and exercise significant latitude in determining objectives and approaches, all while supporting continuous process improvement and compliance.

Responsibilities:

• Intake pharmacy-related issues from care management teams, independently research and determine solutions, and collaborate with others to implement resolutions.
• Lead the Pharmacy Steering Committee, coordinating monthly meetings with market and enterprise pharmacy leadership, setting agendas, facilitating discussions, and conducting follow-up activities.
• Be a consultant to care management regarding member pharmacy needs.
• Participate in state and federal audits as a subject matter expert related to member eligibility.
• Support transition activities with previous pharmacy benefit manager and other vendors, including prescription file transfers, rebate capture, data error resolution, and compliance with CMS and state requirements.
• Identify pharmacy-related challenges and make recommendations for process improvement.
• Analyze pharmacy utilization data, identify trends, and collaborate with leadership and associates to ensure appropriate referrals and interventions.
• Exercise independent judgment to analyze variable factors using data from a variety of pharmacy sources.
• Develop and utilize pharmacy-related policies, job aids, and training materials.
• Partner with Quality Improvement and Care Management teams to monitor pharmacy Star and HEDIS initiatives.

Use your skills to make an impact

Required Qualifications

• Bachelor's degree
• 2 years of data analysis & problem-solving regarding process and workflow concepts
• 2 years of experience with pharmacy benefits management or pharmacy claims
• 2 years of demonstrated proficiency in MS Office applications including Excel, Word, PowerPoint, and Visio

Preferred Qualifications

• Experience with process improvement
• Experience in Medicaid or Medicare

Additional Information

8-430 CST

Home

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$71,100 - $97,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Requisition #: R-419725

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