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

$62,000 - $78,000/Yr

Cambia - Boise, ID

Full-time - Mid Level

Remote - Boise, ID

Insurance Carriers and Related Activities

About the position

The Pharmacy Operations Oversight Specialist plays a crucial role in overseeing pharmacy operations activities carried out by delegated entities. This position involves planning, coordinating, and reporting on various activities such as Prescription Drug Event management, Coverage Determinations, Appeals, and Grievances, Formulary Administration, and Refund and Recovery. The specialist will support audit initiatives, ensuring compliance with CMS, state, and customer requirements while driving continuous improvement in pharmacy operations to enhance the healthcare experience for members.

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, communicating findings and recommendations to stakeholders.
• Conduct follow-up procedures on findings and report on the status of corrective actions taken.
• Stay up-to-date on emerging issues and developments in the health insurance industry, particularly related to Medicare or the Exchange.

Requirements

• Bachelor's degree in a business-related field with at least 3-5 years of Medicare Part D/Pharmacy benefit experience related to eligibility, benefits, and/or claims adjudication, or equivalent combination of education and experience.
• Certified Pharmacy Technician certification is preferred for the Pharmacy Operations Oversight 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.
• Solid understanding of Medicare Part D, Insurance Exchange, and Commercial pharmacy products, as well as CMS and State guidance and PBM claim adjudication systems.
• Proficiency in Microsoft Office products, including Word, Outlook, PowerPoint, Excel, Access, Visio, and SharePoint.
• Skilled at analyzing large amounts of data 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

• Medical, dental, and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance.
• Up to 12 weeks of paid parental time off after 12 months of continuous service.
• Award-winning wellness programs that reward participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.