Manager, Pharmacy Pricing Appeals

Position Summary:

We are seeking a detail-oriented and analytical Manager, Pharmacy Pricing Appeals to join our Provider Relations team. In this role, you will be responsible for managing and resolving the interaction with the pharmacies related to pricing appeals and claims review requests submitted by the pharmacies or internal teams. This includes performing an initial review of the claim and associated pricing, providing the information to internal teams for review, managing any claim adjustments that may be needed, and communicating any necessary information back to the pharmacies. You will play a critical role in ensuring fair reimbursement practices and maintaining strong relationships with pharmacy partners. 

Position Responsibilities:

• Lead the review and improvement of the pharmacy pricing appeal process in coordination with the Analytics team.
• Lead the review and evaluation of the pricing appeal regulatory requirements with the Legal team.
• Manage intake pharmacy pricing appeals or claims reviews from the pharmacies or internal teams via the applicable intake methods required by internal processes and regulations. This involves managing applicable appeal in-boxes and intake methods.
• Evaluate pharmacy-submitted appeals to ensure they meet established criteria and provide the applicable information to the appropriate internal teams for review.
• Receive the internal claim pricing review and respond to the appealing pharmacy with the information.
• Manage the internal process to update any pricing or make claim adjustments as necessary.
• Collaborate with pharmacies and internal teams to reach equitable reimbursement outcomes.
• Provide appeal response information and feedback to the pharmacies as required.
• Provide clear and timely updates to pharmacies and other stakeholders regarding appeal statuses and outcomes.
• Maintain accurate records of appeals and generate reports on trends and discrepancies.
• Lead the development of and manage the claims review process at the NDC level.
• Support other projects as assigned by the Provider Relations team.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Minimum Qualifications:

• Bachelor’s degree required.
• 5+ yrs. of experience in reviewing claims or payment appeals in healthcare, pharmacy, PBM, or other relevant experience. Such prior experience in a pharmacy pricing appeals role includes experience in managing regular correspondence and communication with pharmacies.
• In-depth knowledge of pharmacy operations and drug pricing.
• Familiarity with PBMs and their role in pharmacy reimbursement.
• Strong analytical and problem-solving skills.
• Strong project management skills.
• Excellent communication and interpersonal abilities.
• Experience with and understanding of pharmacy claims processing, pharmacy adjudication systems, and reimbursement workflows.
• Knowledge of state or federal pricing appeal laws.
• Intermediate level of proficiency with Microsoft Excel, Word, PowerPoint.
• Proven track record of working in a fast-paced environment, managing multiple tasks at once and having a go-get attitude to provide persistent outreach to pharmacy providers to close out contracts and tasks.
• Ability to work independently, track work/projects appropriately and remain on task.
• Strong communication skills with the ability to develop effective working relationships with providers and internal and external stakeholders.

Preferred Qualifications:

• Certification in pharmacy technician or related field is a plus.