Senior Analyst

<strong>At Emergent Holdings, we&rsquo;re creating an innovative environment where our employees belong authentically, contribute meaningfully, and thrive intentionally &mdash; both personally and professionally.</strong>

Southfield, USA

Emergent Holdings

<p class="p1"><strong>Emergent Holdings is driven by a singular goal &mdash; improving the health and safety of our customers and our communities. How do we do that? We create innovative insurance products, technology solutions, and services to support our key stakeholders &mdash; individuals, employers, providers, and strategic partners &mdash; improving the health and safety of the people and places we serve.</strong></p>

keywords: job description,claims,customer service,quality assurance,education & experience,knowledge,initiative,skills

Full Time

Competitive Compensation and Benefits Package

Overview: <br />The Senior Analyst position&nbsp;is responsible for assisting Medicare Advantage PPO, HMO and PDP plans meet CMS compliance requirements for PBM oversight, CMS reporting, and benefit set up and testing.<br /><br /> <p><strong>WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards.&nbsp;</p>
Responsibilities: <br /> <ul> <li>Performs a quality review of claims to ensure overall quality.</li> <li>Assists Customer Service with questions and clearly communicates responses to inquiries.</li> <li>Ability to research claims processing concerns and escalate any concerns.</li> <li>Knowledge of Network pharmacy claims processes and ability to assist pharmacies with claims submission.</li> <li>Maintains comprehensive knowledge of the HMO, PPO, and PDP products</li> <li>Recommends and assists with implementing standard policies and procedures.</li> <li>Assures that corporate compliance is communicated, implemented, and monitored on an ongoing basis.</li> <li>Participates in systems testing, develops procedures/controls, and provides recommendations for the ongoing improvement of the updated process.</li> <li>Assists personnel (both internal and external) by answering questions, supplying information, and training.</li> <li>Test annual benefits to ensure claims processing accuracy</li> <li>Develops and maintains an effective working relationship with customers.</li> <li>Participates in group or committee discussions.</li> <li>Assist in CMS and HMO data audits conducted by CMS and internal audit teams</li> </ul>
Requirements: <br /> <p><strong>EDUCATION:</strong></p> <ul> <li>Bachelor&rsquo;s degree in a related field is preferred.&nbsp;</li> <li>Relevant combination of education and experience may be considered in lieu of degree.</li> <li>Continuous learning, as defined by the Company&rsquo;s learning philosophy, is required. &nbsp;</li> </ul> <p>&nbsp;</p> <p><strong>EXPERIENCE:</strong></p> <ul> <li>Two (2) to four (4) years experience as a pharmacy technician or customer service-related field. &nbsp;</li> <li>Experience with Microsoft Office applications including Excel, Word, and Outlook.&nbsp;</li> <li>Must have&nbsp;data analysis, and problem resolution skills.</li> </ul> <p>&nbsp;</p> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Knowledge of pharmacy claim processing and Medicare guidance related to Part D products.</li> <li>Ability to review pharmacy claims and determine if the claim paid appropriately based on the benefit.</li> <li>Ability to understand questions from external areas and articulate timely and accurate responses.</li> <li>Knowledge of pharmacy processes and the ability to assist pharmacies with claims processing.</li> <li>Ability and willingness to learn and take on more responsibilities based on activities with the team.</li> <li>Experience with PBM systems and tools.</li> <li>Analytical, organizational, planning, and problem-solving skills</li> <li>Ability to coordinate work efforts within the team</li> <li>Understanding and knowledge of the business, products, programs, corporate organizational structure (including functional responsibilities), and basic research principles/methodologies</li> <li>Excellent written and verbal communication skills.</li> <li>Ability to lead and contribute to process improvement projects.</li> <li>Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. &nbsp;Ability to deal with problems involving several concrete variables in standardized situations.</li> <li>Administer and adhere to corporate and departmental policies, practices, and procedures.</li> </ul>