Why This Role is Important to Us:
The Pharmacy Operations Specialist is responsible for supporting the operational functions of Commonwealth Care Alliance (CCA) pharmacy program. Operational functions include: claims oversight and resolution, monthly EOB reviews and monthly formulary and pharmacy directory files review and upload. This position requires someone who is highly organized, detail-oriented, personable, and able to adapt to a dynamic environment.
What You'll Be Doing:
CLAIMS OVERSIGHT
- 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
FORMULARY MANAGEMENT
- 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
EXPLANATION OF BENEFITS (EOBs)
- 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
PHARMACY DIRECTORY
- 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
Secondary Duties & Responsibilities:
- 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.
What We're Looking For:
Required Education:
- Associate degree in Healthcare, Nursing, Pharmacy or a related area or equivalent experience required
Desired Education:
- Bachelor's degree preferred
Certified Pharmacy Technician (CPhT) preferred
Required Experience:
- 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)
- Experience working with Medicare Parts B and D and/or Medicaid Plans preferred.
Desired Experience:
- Minimum of 3 years of experience in health care or health insurance industry preferred.
Required Knowledge, Skills & Abilities:
- Proficiency in MS Office: Excel, Word, and PowerPoint required
- MS Visio experience preferred
- Must have 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.
- Must be detail oriented, be able to work independently, and must have solid self-motivation skills.
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Commonwealth Care Alliance
Sep 29, 2024