Remote Pharmacy Operations Analyst

$54,080 - $60,320/Yr

The Csi Companies Inc. Of Florida - Minnetonka, MN

Full-time - Entry Level

Remote - Minnetonka, MN

51-100 employees

About the position

The Remote Pharmacy Operations Analyst plays a crucial role in supporting complex inquiries and escalations related to Medicare Part D. This position is designed for individuals who can work remotely from anywhere in the United States, provided they have a reliable high-speed internet connection and a distraction-free home office environment. The analyst will be responsible for managing first-level responses to pharmacy issues, including complaints and grievances, while serving as a dedicated resource for multiple Medicare Part D plans. This role requires a deep understanding of the Medicare Part D business model, CMS guidance, and Pharmacy Benefit Manager (PBM) claim adjudication systems, which will be applied to real-world scenarios to resolve issues effectively. In this position, the analyst will analyze complex Medicare Part D claims activities to identify and address issues that are not predefined in workflows. They will provide clear direction to Pharmacy Benefit Managers on behalf of the plan and its members. Additionally, the analyst will participate in readiness activities for the new benefit plan year, which includes familiarizing themselves with plan nuances and collaborating with Product and Clinical teams to resolve inquiries. Investigating and resolving issues related to enrollment, billing, claims, and customer service will also be a key responsibility, with findings and resolutions communicated to stakeholders. This role is full-time, operating Monday through Friday from 9 AM to 5 PM CST, and offers a competitive hourly wage based on experience, with overtime paid at 1.5 times the normal rate.

Responsibilities

• Manage first-level responses and resolve escalated pharmacy issues for Medicare Part D plans, working directly with internal and external clients via phone, email, and SharePoint.
• Understand the overall business model of Medicare Part D products, CMS guidance, and Pharmacy Benefit Manager claim adjudication systems, and apply these concepts to real-world scenarios.
• Analyze complex Medicare Part D claims activities to identify and address issues not predefined in workflows, providing clear direction to Pharmacy Benefit Managers on behalf of the plan and members.
• Participate in readiness activities for the new benefit plan year, including familiarizing yourself with plan nuances and collaborating with Product and Clinical teams to resolve inquiries.
• Investigate and resolve issues related to enrollment, billing, claims, and customer service, communicating findings and resolutions to stakeholders.

Requirements

• 3 years Medicare Part D/Pharmacy benefit, and/or PBM experience related to eligibility, benefits and/or claims adjudication.
• High school diploma or equivalent.
• Minimum of 1 years' experience Pharmacy claim analysis and quality practices.
• A reliable high-speed internet connection (the faster the better!).
• Ability to pass a background check and drug test.
• Private, quiet, and distraction-free workspace in a room with a closed-door.

Nice-to-haves

• Large corporation experience.
• Health plan / managed care / healthcare industry experience.
• Bachelor's degree or equivalent work experience.
• Knowledge of RxClaim processing system.
• Knowledge of Medicare Part D guidelines and regulations.
• Experience with Prior Authorization systems and guidelines in compliance with CMS regulation.

Benefits

• Weekly pay
• Medical, dental, and vision coverage
• Voluntary Life and AD&D coverage
• Paid Training
• Opportunity for advancement upon performance and availability