Manager, Fund Administration

Overview

 Amalgamated Employee Benefits Administrators (AEBA) provides third party benefit administration (including pension, medical and collections and billing) to self-insured clients. As the Manager of Fund Administration at AEBA, you will play a pivotal role in our continued success. The responsibilities for this position includes managing the pharmacy benefits for multiple clients, as well as account management of pharmacy benefits for our internal pharmacy benefits product.  The Manager is also responsible for working with our Claims Department to manage all Medicare Demands with daily communications with CMS.  The Manager will also be managing the Subrogation activity for our clients.  This includes all attorney communications, interaction with our Subrogation vendor, creating and mailing lien packages, and working with internal Claims Department to ensure claims are processed.

Responsibilities

  CVS Pharmacy Benefit (ANHF) 

• Processing Weekly Invoices 
• Diabetic Management Program (working with Case Managers) 
• Manual Updates in CVS system 
• Review/Approval Prior Authorizations 
• Special Mailing Drug Cards 
• Medicare D Mailing (Annually; Includes Local 99 and HMO & BCBS-MA Members) 
• Trouble-shoot issues with weekly file 
• Interaction with PBM Consultants 

   AEBRx Pharmacy Benefit 

• Manual Eligibility for AEBRx in ECI and (sometimes) Magellan 
• Bi-Monthly Invoices – processing payments to Magellan and providing information to Finance for providing invoices to clients for payment 
• Providing Requested Reports to Consultant/Fund 
• Working with Magellan on member prescription issues 

   Medicare Demands (All Funds) 

• Medicare Demands are routed to me for response. The process includes review of eligibility. Reviewing claims for which they are seeking reimbursement (do we already have them in the system; were they paid as primary or secondary already; do we need to have the examiner enter the claim in the system.  Printing of any/all related EOB’s. Having checks processed to pay pulled for manual handling. Compile all documentation and respond to CMS within the appropriate time frame.  Response must address each claim with a “valid” reason if non-payment.  Be prepared to work on this for the next three years unless you are paying 100% of what they ask. 

   Subrogation (All Funds) 

• Creating/mailing initial lien packages – obtaining doc no. and updating ECI notes 
• Handling Attorney calls and providing attorney responses via email, fax and/or mail.  Includes providing copies of 5500 Forms for specific Fund, creating PDF copies of related claims and EOBs to send electronically or, if necessary, via encrypted CD 
• Creating benefits statement to provide lien information to attorney OR referring to Optum for response and taking us out of the loop (which has never been the route I have chosen) This includes reviewing all paid claims in member history that appear to be related to the accident that occurred.  Also review of unpaid claims that might need to be addressed prior to any settlement to ensure they are not submitted after a recovery has already been made. 
• Interaction with Subrogation Vendor, Optum.  Provide Finance with Breakdown of Monthly Recoveries (Where to deposit the money and how much) Provide Raj with copy of report and breakdown so that refunds can be applied in Eldorado. 
• Accessing vendor system for reporting and for updating in cases of retractions being requested. 
• Work with Claims to ensure claims are processed once documentation has been received or once working with attorney on resolution. 

Qualifications

• College degree preferred or at least 5 years' experience required. 
• Microsoft Office experience including Word, Excel and PowerPoint.  Ability to train and navigate through multiple internal computer systems.  High level communication skills required.  Must be willing to take initiative and multi-task on several different duties and responsibilities.