Pharmacy Operations Specialist Specialist, Remote

Commonwealth Care Alliance - Boston, MA

Full-time

Boston, MA

Ambulatory Health Care Services

About the position

The Pharmacy Operations Specialist plays a crucial role in supporting the operational functions of the Commonwealth Care Alliance (CCA) pharmacy program. This position is integral to ensuring the smooth operation of pharmacy-related activities, which include claims oversight, formulary management, and the review of Explanation of Benefits (EOBs) and pharmacy directories. The specialist will be responsible for daily and monthly reviews of claims to ensure proper adjudication, as well as managing the creation and maintenance of formularies across all lines of business. This role requires a highly organized and detail-oriented individual who can adapt to a dynamic environment and work collaboratively with various stakeholders. In the claims oversight function, the specialist will conduct daily reviews of rejected and paid claims, ensuring that all claims are processed correctly and that any issues are escalated to pharmacy management and the Pharmacy Benefit Manager (PBM) as necessary. The role also involves identifying systemic issues with claims configuration and resolving them in a timely manner. Formulary management is another key responsibility, where the specialist will utilize formulary management tools to create, maintain, and submit formularies. They will support the pharmacy operations team in analyzing monthly and yearly formulary submissions and review monthly reports to ensure timely processing of prior authorizations by the PBM. The monthly review of EOBs is essential to ensure the accuracy of information, and any discrepancies will need to be escalated to pharmacy management and the PBM. Additionally, the specialist will review pharmacy directories monthly to ensure data accuracy and resolve any identified issues promptly. Secondary duties include tracking pharmacy-related inquiries from both internal and external stakeholders, supporting departmental initiatives and projects, and serving as a resource for others within the department. This position is vital for maintaining the integrity and efficiency of the pharmacy operations at CCA.

Responsibilities

• 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
• 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
• 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
• 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
• 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.

Requirements

• Associate degree in Healthcare, Nursing, Pharmacy or a related area or equivalent experience required
• 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)
• Minimum of 3 years of experience in health care or health insurance industry preferred
• Proficiency in MS Office: Excel, Word, and PowerPoint required
• 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
• Detail oriented, able to work independently, and possess solid self-motivation skills.

Nice-to-haves

• Bachelor's degree preferred
• Certified Pharmacy Technician (CPhT) preferred
• MS Visio experience preferred
• Minimum of 3 years of experience in health care or health insurance industry preferred.