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Humana Pharmacy Claims Lead- Overpayment in Springfield, Missouri


The Pharmacy Claims Lead - Overpayment works on problems of diverse scope and complexity ranging from moderate to substantial. The Pharmacy Claims Lead will lead the development and implementation for overpayment programs including: Medicare Secondary Payer, Commercial COB, Commercial vs Medicare Part B and Commercial Retro-term. May include additional overpayment processes related to Medicare Part A vs Medicare Part D, Medicare Part B vs Medicare Part D and review of pharmacy claims containing invalid claim elements.


The Pharmacy Claims Lead analyzes and answers inquiries regarding pharmacy claims adjudication, including method of payment, co-pay or deductible amounts, and/or reason for denial. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, Uses independent judgment requiring analysis of variable factors and determining the best course of action.

Job Duties to include the following:

  • Lead development and implementation of the following overpayment programs:

  • Medicare Secondary payer, including build of payer to payer system

  • Commercial COB

  • Commercial vs Medicare Part B

  • Commercial Retro-term

  • Develop analytics and reporting needed to support the day-to-day business

  • Establish solid metrics surrounding inventory management which include the following:

  • Cycle time reporting to ensure cases are handled according to state and federal guidelines where applicable

  • Reporting to calculate days on hand inventory

  • Reporting to calculate daily receipts

  • Productivity reporting to aid in ensuring that the organizational goals are met

  • Quality reporting to ensure legislative and process adherence

  • Develop and document processes

  • Write and maintain policies and procedures; while ensuring policies and procedures address compliance and regulatory requirements

  • Effectively collaborate with other Humana departments and Pharmacy Claim Audit and Review teams

  • Participate in implementation of new auditing system

  • Responsible for ensuring system includes all aspects of new work streams

  • Additional projects assigned, based on business needs

Required Qualifications

  • Bachelor's degree with 3+ years of Pharmacy Claims experience, or 8+ years of equivalent experience

  • Strong background in leading and developing the implementation of the work.

  • Data Driven, strong business acumen, analytical & problem solving skills

  • Demonstrated ability to manage multiple projects and meet deadlines, and follow in a timely manner

  • Comprehensive knowledge of all Microsoft Office applications, including Word, Excel and PowerPoint

  • Exceptional, organizational, interpersonal, written, and oral communication and presentation skills

  • Strong organizational and time management skills

  • Self-Starter, works well without direction & can lead own work

  • Ability to collaborate with multiple cross functional teams, payers & vendors, and interact with leadership internally and externally

  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

  • Previous experience with pharmacy benefits management

  • Previous experience with Medicare Secondary Payer process

  • Knowledge/experience working with SQL (via MS SQL Server, Oracle, PL/SQL or other)

  • Knowledge/experience working with Microsoft Access

  • Pharmacy Tech experience

  • Experience with analytic tools and utilization data

  • Experience or background with Six Sigma

  • Experience with pharmacy overpayment processes

Additional Information

Interview Format:

As part of our hiring process for this opportunity, we may use an exciting interviewing technology called Montage Voice to enhance our hiring and decision-making ability. Montage Voice allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected for a first-round interview, you may receive an email correspondence inviting you to participate in a Montage Voice/Text interview. In this interview, you will listen/read a set of interview questions over your phone or computer and you will provide recorded/typed responses to each question. You should anticipate this interview to take about 15 minutes. Your recorded/text interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

  • Alert:

Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana's secure website.

Scheduled Weekly Hours