Pharmacy Operations Oversight Specialist or Pharmacy Operations Oversight Specialist Sr. - DOE

Cambia - Pocatello, ID

Full-time - Mid Level

Pocatello, ID

Insurance Carriers and Related Activities

About the position

The Pharmacy Operations Oversight Specialist plays a crucial role in overseeing pharmacy operations activities at Cambia Health. This position involves planning, coordinating, and reporting on various pharmacy-related activities, ensuring compliance with CMS, state, and customer requirements, and driving continuous improvement in pharmacy operations. The role is focused on creating a person-centered health care experience for members by managing oversight activities and supporting audit initiatives.

Responsibilities

• Contribute to the development and implementation of oversight, monitoring, and audit plans for healthcare providers and contracted entities.
• Partner with internal departments to ensure contracts with healthcare providers include updated and relevant contractual language.
• Conduct audits and examinations to ensure compliance with operational expectations and regulatory requirements.
• Document work clearly and concisely, including writing formal reports and assessing identified findings.
• Coordinate monitoring efforts with office managers, operations officers, and external entities, and communicate findings and recommendations to stakeholders.
• Conduct follow-up procedures on findings and report on the status of corrective actions taken, and conduct special projects and investigations as requested.
• Stay up-to-date on emerging issues and developments in the health insurance industry, particularly related to Medicare or the Exchange.

Requirements

• Preferred Bachelor's degree in a business-related field with at least 3-5 years of Medicare Part D/Pharmacy benefit PBM experience related to eligibility, benefits, and/or claims adjudication, or equivalent combination of education and experience.
• Certified Pharmacy Technician certification is preferred for the Specialist role.
• Bachelor's degree in a business-related field with at least eight years of benefit PBM experience related to eligibility, benefits, and/or claims adjudication, or equivalent combination of education and experience for the Senior role.
• Certified Pharmacy Technician certification is preferred for the Senior role.
• Solid understanding of Medicare Part D, Insurance Exchange, and Commercial pharmacy products, as well as CMS and State guidance and PBM claim adjudication systems.
• Proficient in Microsoft Office products, including Word, Outlook, PowerPoint, Excel, Access, Visio, and SharePoint.
• Skilled at analyzing large amounts of data, handling complex requests, and developing reports and executive summary documents.
• Knowledge of pharmacy claims processing systems, particularly RxClaim.

Nice-to-haves

• Experience with business analysis and continuous process improvement.
• Familiarity with Pharmacy Claim Analysis and quality practices.

Benefits

• Work from home options in Oregon, Idaho, and Utah.
• Career development opportunities in a person-focused health care system.