Navitus Health Solutions

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Claims and Recoveries Coordinator

at Navitus Health Solutions

Posted: 10/24/2017
Job Reference #: 5000262187506

Job Description

Requisition Number



Appleton Campus: Appleton, Wisconsin

Other Locations



Bachelor's degree strongly desired, or equivalent experience


Minimum 1-3 years' knowledge of pharmaceutical claims adjudication systems, retail pharmacy, or health insurance

Job Description

This position may include after-hour and/or weekend hours with other eligible team members depending on workload.

Job Summary:

The Claims and Recoveries, Coordinator I position is responsible for successful implementation and maintenance of member data for all Client combined benefit needs. TheCoordinator Iis responsible for testing the initial set-up of accumulators; as well managing the day to day processes and changes made to a client's combined benefit. This role requires knowledge of both the technical and operational sides of the business. Candidates will have direct authority to make sound business decisions with regard to client data. Candidates need to have a working knowledge of eligibility processes, plan designs, and claims processing. The Coordinator I, will work closely with the Sr. Product Manager of Combined Benefits, Data Services, Claims Adjudication Development, Client Services, Benefit Systems, and Navitus' system vendor to understand the interdependences of each. The Coordinator I also needs to be able to support and mentor others as it relates to combined benefits.

Job Responsibilities:

  • Is responsible for successful electronic accumulator file loads to the Claims Adjudication System within specified client performance guarantee timeframes, guarding client and Navitus from potentially high dollar financial liabilities
  • Reports all errors to Client contacts and/or Client Services within one business day of loading the files
  • Requests, validates and confirms full file data feeds from Clients to ensure system integrity through audits and reconciliation, and independently assesses business needs for Navitus system improvements or recommends solutions to Product Manager, Combined Benefits.
  • Learn and abide by regulatory requirements to accurately process accumulator files ensuring compliance with state and federal regulations and fulfillment of Client performance standards
  • Participates in review to update internal team documentation
  • Participates in process re-design of team initiatives
  • Utilizes self-directed, sound business judgment and expertise to identify, define, and document providing necessary detail to process of accumulator files
  • Participates with communicating to all departments the nature of processing accumulator files; providing talking points for Member Services to explain Rx Only and Combined Benefits to members, pharmacies, and Client Services or Government Programs to explain corrective outcomes
  • Runs necessary reports to identify overall impact to assist with troubleshooting issues
  • Works with Eligibility Analysts and Coordinators with troubleshooting, root cause analysis, and solution implementation for eligibility issues relating to accumulator file
  • Maintains a working knowledge of plan designs and claims processing functionality
  • Is proficient with working and understanding systems
  • Protects all personal health information and abide by all HIPAA regulations and confidentiality requirements