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Pharmacy Operations Specialist Specialist, Remote

Remote:

Full Remote

Contract:

Full time

Salary:

6 - 10K yearly

Experience:

Senior (5-10 years)

Work from:

United States

Offer summary

Qualifications:

Associate degree in Healthcare or related field required, Bachelor's degree preferred, Certified Pharmacy Technician (CPhT) preferred, Experience in retail, hospital, or managed care pharmacy, 3 to 5 years' experience in healthcare claims coding and billing.

Key responsabilities:

Review and resolve daily and monthly claims
Manage formulary submissions and updates
Conduct monthly EOB accuracy checks
Maintain pharmacy directory data accuracy
Respond to pharmacy-related inquiries

Commonwealth Care Alliance Health Care Large https://www.commonwealthcarealliance.org/

1001 - 5000 Employees

See more Commonwealth Care Alliance offers

Job description

Your missions

Why This Role Is Important To Us

The Pharmacy Operations Specialist is responsible for supporting the operational functions of Commonwealth Care Alliance (CCA) pharmacy program. Operational functions include: claims oversight and resolution, monthly EOB reviews and monthly formulary and pharmacy directory files review and upload.

This position requires someone who is highly organized, detail-oriented, personable, and able to adapt to a dynamic environment.

What You'll Be Doing

CLAIMS OVERSIGHT

Daily reject and paid claims review to ensure proper adjudication
Daily and monthly transition claims review to ensure proper adjudication, claims messaging occur, and letters sent to members in a timely fashion
Escalate to pharmacy management and PBM on issues with claims
Identify systemic issue with configuration
Resolve issues in a timely manner

FORMULARY MANAGEMENT

Create, maintain, submit, and post formularies using formulary management tool for all lines of business
Support pharmacy operations team in the analysis of monthly and yearly formulary submissions.
Review monthly CDAG reports for timeliness of PAs processed by PBM

EXPLANATION OF BENEFITS (EOBs)

Monthly review of EOBs to ensure accuracy of information
Escalate to pharmacy management and PBM when issues are identified
Identify systemic issue with configuration
Resolve issues in a timely manner

PHARMACY DIRECTORY

Monthly review of pharmacy directories to ensure accuracy of data to our external vendor
Escalate to pharmacy management and external vendors when issues are identified
Resolve issues in a timely manner

Secondary Duties & Responsibilities

Track and formally respond to pharmacy related inquiries from internal and external stakeholders
Support department initiatives and projects as assigned
Serve as a resource to others within the department.

Required Education

What We're Looking For:

Associate degree in Healthcare, Nursing, Pharmacy or a related area or equivalent experience required

Desired Education

Bachelor's degree preferred Certified Pharmacy Technician (CPhT) preferred

Required Experience

Experience in retail, hospital, or managed care pharmacy industry required.
Experience working with Medicare Parts B and D and/or Medicaid Plans preferred.
3 years' coding, billing, auditing of healthcare claims, or investigative experience (for a
Level I position) or 5 years' coding, billing, and auditing of healthcare claims, or investigative experience (for a Level II position)
Experience working with Medicare Parts B and D and/or Medicaid Plans preferred.

Desired Experience

Minimum of 3 years of experience in health care or health insurance industry preferred.

Required Knowledge, Skills & Abilities

Proficiency in MS Office: Excel, Word, and PowerPoint required
MS Visio experience preferred
Must have excellent oral and written communication skills, including preparation of presentation-ready materials.
Excellent analytical skills necessary to interpret pharmacy data and reports
Proven time management and organizational skills.
Ability to manage multiple tasks, workflows and responsibilities that can vary significantly across business lines
Capable of working in a fast-paced environment while maintaining accuracy in all elements of the position.
Must be detail oriented, be able to work independently, and must have solid self-motivation skills.