Pharmacy Operations Manager

2 weeks ago


Boston, United States Planet Professional Full time

Pharmacy Operations Specialist

Contract

$30-33.50/hr

Estimated Duration through January 2025

Fully Remote


  • Required:
  • Intermediate or better excel
  • Strong attention to detail
  • Experience in retail, hospital, or managed care pharmacy industry required.
  • 3 or more years experience coding, billing, auditing of healthcare claims, or investigative experience
  • Experience working with Medicare Parts B and D and/or Medicaid Plans
  • Clear and professional written and verbal communication skills



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


Position Summary:

The Pharmacy Operations Specialist plays a crucial role in ensuring the efficient operation of our pharmacy program. This role encompasses overseeing claims, managing formularies, reviewing Explanation of Benefits (EOBs), and maintaining the accuracy of pharmacy directories. The ideal candidate is highly organized, detail-oriented, personable, and adaptable to a dynamic work environment.

Responsibilities:

  • Claims Oversight:Review daily rejected and paid claims to ensure accurate adjudication.
  • Monitor daily and monthly transition claims for proper adjudication, timely messaging, and prompt letter dispatch to members.
  • Escalate issues to pharmacy management and PBM when necessary.
  • Identify and address systemic configuration issues.
  • Resolve claims-related issues in a timely manner.
  • Develop, maintain, and submit formularies using formulary management tools across all business lines.
  • Assist the pharmacy operations team with the analysis of monthly and yearly formulary submissions.
  • Review monthly CDAG reports to ensure the timely processing of Prior Authorizations (PAs) by the PBM.
  • Explanation of Benefits (EOBs):Conduct monthly reviews of EOBs to verify the accuracy of information.
  • Escalate discrepancies to pharmacy management and PBM as needed.
  • Identify and resolve systemic issues with configurations.
  • Pharmacy Directory:Review pharmacy directories monthly to ensure the accuracy of data provided to external vendors.
  • Address and escalate issues to pharmacy management and external vendors.
  • Resolve directory-related issues promptly.
  • Secondary Duties & Responsibilities:Track and respond to pharmacy-related inquiries from internal and external stakeholders.
  • Support departmental initiatives and projects as assigned.
  • Serve as a resource for colleagues within the department.
  • Education Requirements:Associate degree in Healthcare, Nursing, Pharmacy, or a related field, or equivalent experience required.
  • Bachelor’s degree preferred.
  • Certified Pharmacy Technician (CPhT) preferred.
  • Experience Requirements:Required: Experience in retail, hospital, or managed care pharmacy industry.
  • Preferred: Experience with Medicare Parts B and D and/or Medicaid Plans.
  • Level I: 3 years of experience in coding, billing, auditing of healthcare claims, or investigative work.
  • Level II: 5 years of experience in coding, billing, auditing of healthcare claims, or investigative work.
  • Desired Experience:Minimum of 3 years of experience in the healthcare or health insurance industry.
  • Knowledge, Skills, and Abilities:
  • Proficiency in MS Office (Excel, Word, PowerPoint) required; MS Visio experience preferred.
  • Excellent oral and written communication skills, including the ability to prepare presentation-ready materials.
  • Strong analytical skills to interpret pharmacy data and reports.
  • Effective time management and organizational skills.
  • Ability to manage multiple tasks and responsibilities across different business lines.
  • Capability to work accurately in a fast-paced environment.
  • Detail-oriented with the ability to work independently and demonstrate strong self-motivation.



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