Summary of Job Responsible for overseeing daily operations and administrative functions to ensure efficient pharmacy workflow and a positive patient experience. Provide a combination of operational oversight and customer service resolution. Oversee daily non-clinical operations like medical drug processing to ensure compliance with regulations. Drive operational excellence by identifying process inefficiencies and systemic gaps across core pharmacy functions. Ensure that appealed decisions are updated/reflected in the system, and to internal staff as well as providers. Serve as primary point of contact for escalated pharmacy-related issues, discrepancies, pricing errors, and benefit configurations. Work with Pharmacy Benefits Mgr. (PBM) to resolve escalated issues. Directly communicate w/enterprise leaders/teams including UM, Claims, IT/Data, PBM, Compliance, Pharmacy, etc. Responsibilities
- Engage with members on pharmacological escalations to resolve complaints.
- Coordinate with PBM partners and internal departments (Claims, Configuration, Clinical and Legal) to ensure timely and accurate resolution of complex issues.
- Maintain escalation logs, documentation, and resolution timelines to support compliance and trend analysis.
- Direct, triage, and resolve escalations impacting providers and members, ensuring root cause analysis and corrective action plans.
- Drive pharmacy operational readiness for new initiatives (PBM transitions, formulary changes, frozen formulary rules, state mandates.
- Contribute to the development and maintenance of internal SOPs, escalation workflows, and FAQs for consistent issues handling.
- Monitor daily rejected claims, accumulator discrepancies and eligibility-related fallouts queues to identify systemic issues and escalated as needed.
- Contribute to operational dashboards and scorecards with experience-focus KPI(s).
- Responsible for regulatory compliance and reporting; for managing insurance point of sale claims escalations; for analyzing financials and operations; and coordinating member outreach to ensure appropriate outcomes.
- Provide weekly summaries or reporting packages to leadership outlining key findings, resolution status, and recommendations.
- Support day-to-day operations across pharmacy benefit configuration group onboarding, adjustment claim submission and review, and file outbound and inbound validation.
- Perform other projects and duties as assigned.
- Support training efforts and knowledge-sharing for new staff or cross-functional partners regarding pharmacy operations and escalation protocols.
Qualifications
- Bachelor's degree
- 5 - 8+ years of relevant, professional work experience (Required)
- 5+ years of pharmacy operations experience (Required)
- Additional years of related experience/specialized training may be considered in lieu of degree requirement (Required)
- Ability to perform in office environment with extended periods of sitting, using telephone, and viewing computer screens (Required)
- Ability to prioritize tasks daily and troubleshoot urgent customer issues to successful completion (Required)
- Advanced knowledge of MS Office - Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc. (Required)
- Exceptional problem solving, analytical, interpersonal and communication skills to resolve issues within Operations (Required)
- Professionally skilled in verbal and written communication (Required)
- Meticulous organization skills, with the ability to multi-task, and ability to make sound decisions in a timely and independent manner (Required)
Additional Information
- Requisition ID: 1000002784
- Hiring Range: $77,760-$149,040
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EmblemHealth
Nov 11, 2025