Part D Claims Specialist

Part D Claims Eligibility Specialist is responsible for performing a range of tasks related to claims and compliance for the Innov Age Part D plan. This includes managing and reconciling Part A claims and stays, managing participant plan enrollment status with the pharmacy and PBM, ensuring that claims are billed to Part D appropriately based on CMS regulations and EMR documentation, and working closely with Medicare, Medicaid, finance, and billing specialists.

The role requires being detail oriented, comfortable managing large volumes of data and working independently.

Work-from-Home position.

• Reconcile and manage Part A claims and stays
• Perform Part D compliance tasks, including B vs D, ESRD, Medical Necessity, etc.
• Download and review weekly, monthly and quarterly Part D and PBM (Pharmacy Benefits Manager) reporting and take necessary actions
• Download and review CMS reports and take necessary actions
• Reconcile rejected claims and submission concerns with pharmacies and PBM
• Assist in the reconciliation of PDE (Prescription Drug Event) data
• Summarize and report PDE progress
• Prepare, submit, and analyze PDE submissions to CMS
• Stay current on pharmacological updates and Medicare Part D Guidelines
• Coordinate with Medicare and Medicaid specialists as needed
• Work with finance and billing specialists on bill resolution
• Manage provider credentials for our PBM and contracted pharmacy
• Perform other duties as needed

• 3+ yrs working with medical and/or pharmacy claims.
• Current advanced knowledge in medication names, dosages, indications, and routes of administration.
• Experience and comfort navigating EMR and interpreting EMR data
• Advanced skills using Excel to manage large volumes of data - formulas, pivots, reports
• Ability to solve problems under pressure
• Strong attention to detail and able to prioritize workload
• Comfortable working independently
• Excellent communication and organization skills
• Strong computer skills including word processors, spreadsheets, and database software.
• Associate’s degree or formal training beyond high school in lieu of Associates

• Bachelor’s degree
• Experience in EPIC EMR
• Experience managing patient plan eligibility
• Experience in a PACE or similar healthcare program
• Knowledge of Medicare Part D regulations and compliance requirements

Innov Age is dedicated to empowering seniors to live independently, allowing them to age in their own homes and communities safely. Innov Age offers an alternative to nursing homes through its Program of All-inclusive Care for the Elderly (PACE), which provides enrolled seniors with customized healthcare and social support at PACE Adult Day Health Centers. These centers are staffed by medical professionals who are committed to creating personalized care plans for each participant.

At Innov Age, our team members are our greatest asset and have a significant impact on the lives of our participants every day. When you join Innov Age, you'll work alongside talented, respectful, and passionate colleagues within a patient-centered care model.

Innov Age is committed to equal opportunity and affirmative action, and we strive to create a diverse and inclusive workplace. We consider all qualified candidates for employment without discrimination based on race, color, religion, sex, sexual orientation, gender identity/expression, national origin, disability, protected veteran status, pregnancy, or any other protected status. Salaries are determined by various factors such as qualifications, experience, and location, and do not include potential bonuses or benefits.

Our extensive benefits package includes medical/dental/vision insurance, short and long-term disability, life insurance and AD&D, supplemental life insurance, flexible spending accounts, 401(k)…