Pharmacy Ops Oversight Specialist

Join to apply for the Pharmacy Ops Oversight Specialist role at Regence BlueCross BlueShield of Utah Work from home within Oregon, Idaho, or Utah About the Role We are looking for a Pharmacy Operations Oversight Specialist to support the planning, coordination, execution, and reporting of pharmacy operations activities carried out by partners that provide Pharmacy Benefit Management services to Cambias Medicare Part D, Exchange, or commercial portfolio. Key Responsibilities Oversight of vendor delegated responsibilities such as Prescription Drug Event (PDE), Coverage Determinations, Appeals, and Grievances (CDAG), Formulary Administration (FA), Refund and Recovery (RR), and other assigned functions. Support CMS, state, and customer audit initiatives by investigating samples, identifying concerns, researching claims, and evaluating reports to identify oversight gaps. Assist in the development and implementation of oversight, monitoring, and audit plans related to Regences healthcare providers and contracted entities. Partner with internal departments to ensure contracts contain updated contractual language. Request operational attestations, examine documentation, interview contacts, and perform procedures to ensure compliance with expectations and regulatory requirements. Document findings, communicate identified issues, and develop written findings for non-operational gaps. Coordinate monitoring efforts with office managers, officers, and external entities. Write and edit formal reports and reports on the status of corrective actions. Conduct special projects and investigations as requested, staying abreast of industry developments. Qualifications Bachelors degree in a business-related field. 35 years of Medicare Part D/Pharmacy benefit, PBM experience related to eligibility, benefits, and/or claims adjudication (minimum for Specialist). At least 8 years of related experience for Senior Specialist. Certified Pharmacy Technician certification preferred. Skills and Attributes Demonstrated understanding of Medicare Part D and/or insurance exchange/commercial pharmacy products, CMS and state guidance, and PBM claim adjudication systems. Ability to translate compliance concepts into practical operational oversight. Proficiency with Microsoft Office (Word, Outlook, PowerPoint, Excel, Access, Visio, SharePoint). Experience with business analysis and continuous process improvement. Analytical skills for handling large data sets and complex requests. Report development and executive summary creation. Pharmacy claim analysis and quality practice knowledge. Knowledge of pharmacy claims processing systems, particularly RxClaim. Experience with AI tools and technologies to enhance productivity (highly desired). Additional Functions for Senior Specialist Maintain and deliver oversight reports and program updates to compliance teams. Compile executive-level summaries of compliance programs. Design oversight programs targeting high-risk areas to mitigate compliance vulnerability. Collaborate with compliance leadership strategically at the plans. Work Environment Travel required locally or out of state. May be required to work outside of normal hours. Compensation The expected hiring range for a Pharmacy Ops Oversight Specialist is $57,000 $78,000 per year, with a 5% bonus target. The full salary range is $57,000 $95,000 per year. The expected hiring range for a Pharmacy Ops Oversight Specialist Senior is $71,000 $89,000 per year, with a 10% bonus target. The full salary range is $71,000 $116,000 per year. Benefits Medical, dental, and vision coverage for employees and eligible families, including mental health benefits. Annual employer contribution to a health savings account. Generous paid time off, varying by role and tenure, plus 10 company-paid holidays. Market-leading retirement plan with company match on 401(k) contributions and potential discretionary contribution. Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service). Award-winning wellness programs. Employee Assistance Fund. Commute and parking benefits. We are an Equal Opportunity Employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status, or any other status protected by law. A background check is required. If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. #J-18808-Ljbffr