Claims Operations Specialist

Claims Operations Specialist

SmithRx is a rapidly growing, venture-backed Health-Tech company. Our mission is to disrupt the expensive and inefficient Pharmacy Benefit Management (PBM) sector by building a next-generation drug acquisition platform driven by cutting edge technology, innovative cost saving tools, and best-in-class customer service. With hundreds of thousands of members onboarded since 2016, SmithRx has a solution that is resonating with clients all across the country.

We pride ourselves for our mission-driven and collaborative culture that inspires our employees to do their best work. We believe that the U.S healthcare system is in need of transformation, and we come to work each day dedicated to making that change a reality. At our core, we are guided by our company values:

• Integrity: Our purpose guides our actions and gives us confidence in the path ahead. With unwavering honesty and dependability, we embrace the pressure of challenging the old and exemplify ethical leadership to create the new.
• Courage: We face continuous challenges with grit and resilience. We embrace the discomfort of the unknown by balancing autonomy with empathy, and ownership with vulnerability. We boldly challenge the status quo to keep moving forward—always.
• Together: The success of SmithRx reflects the strength of our partnerships and the commitment of our team. Our shared values bind us together and make us one. When one falls, we all fall; when one rises, we all rise.

Job Summary:

As a Claims Specialist, you will play a pivotal role in ensuring exceptional member satisfaction and operational efficiency within our dynamic Health-Tech environment. You will be responsible for the accurate and timely processing of complex non-electronically submitted claims, including direct member reimbursements and commercial out-of-network claims. Beyond routine processing, this role demands proactive problem-solving, acting as a critical liaison between members and our clinical team for denied reimbursements, and initiating prior authorization processes to ensure seamless continuity of care. You will leverage your expertise to uphold claims integrity, drive process improvements, and provide essential cross-functional support to our account management, member support, and other customer success teams, contributing directly to our mission of transforming healthcare. Projects and other tasks that may arise and be assigned as needed.

What you will do:

• Responsible for ensuring timely completion of non-electronically processed claims such as direct member reimbursement claims and commercial out-of-network claims.
• Ensure claims approvals and/or denials are made in accordance with company practices and procedures. Timely execution on member communications at scale, including mail-outs through our third-party mail vendor.
• Maintain reimbursement queue to meet the department's SLA's. Completion of assigned claim cases in accordance with daily expectations.
• Sustain integrity of all existing claims processes by ensuring all process documentation is up to date.
• Participate in process improvement and quality assurance opportunities.
• Collaborate and provide cross-functional support to account management, member support, and other customer success teams.
• Act as a liaison between the clinical team and the member for denied reimbursements, initiating the prior authorization (PA) process to ensure proactive member support.
• Participate in internal meetings to help support initiatives and projects.
• Ability to prioritize and complete high-volume cases/claims.

What you will bring to SmithRx:

• 2+ year of experience in a healthcare claims role, preferably in a pharmacy setting or licensed as a pharmacy technician.
• Prior working knowledge of medical or pharmacy claims processing.
• Excellent organization skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity.
• Microsoft Excel skills required.
• Impeccable attention to detail and accuracy in work.
• Strong problem solving, written and verbal communication, and interpersonal skills
• Ability to work independently as well as part of an extended, cross-functional team
• Self-driven, results-oriented work ethic with a positive outlook
• Ability to take initiative with little to no direction

What SmithRx Offers You:

• Highly competitive wellness benefits including Medical, Pharmacy, Dental, Vision, and Life and AD&D Insurance
• 3 Weeks Paid Time Off
• 12 Paid Holidays
• Paid Parental Leave Benefits
• Flexible Spending Benefits
• 401(k) Retirement Savings Program
• Short-Term and Long-Term Disability
• Wellness Benefits
• Commuter Benefits
• Employee Assistance Program (EAP)
• Well-stocked Kitchen In Office Locations
• Professional Development and Training Opportunities