Pharmacy Ops Oversight Specialist

Pharmacy Ops Oversight Specialist Join to apply for the Pharmacy Ops Oversight Specialist role at Regence BlueShield of Idaho. Work from home within Oregon, Idaho, or Utah. About the Role Every day, Cambias dedicated team of Pharmacy Ops Oversight Specialists are living our mission to make health care easier and lives better. As a member of the Pharmacy Operations team, our Specialists assist in planning, coordinating, conducting, and reporting on pharmacy operations activities carried out by delegated entities that provide Pharmacy Benefit Management services to Cambias Medicare Part D, Exchange, or commercial portfolio. The job involves oversight of vendors delegated responsibilities, including Prescription Drug Event (PDE), Coverage Determinations, Appeals, and Grievances (CDAG), Formulary Administration (FA), Refund and Recovery (RR), and other operations oversight functions as assigned. Support CMS, state, and customer audit initiatives by investigating samples, identifying potential gaps, researching claims within the pharmacy system, and evaluating reports with a focus on identifying issues in existing oversight activities. Responsibilities Assist in developing and implementing oversight, monitoring, and audit plans related to Regences healthcare providers and other contracted entities. Partner with internal departments to ensure that contracts include updated and relevant contractual language. Request operations attestations, examine documentation, interview operations contacts, and perform procedures necessary to ensure compliance with expectations and regulatory requirements. Document work performed and create clear written findings regarding non-compliance. Coordinate operations monitoring efforts with office managers, operations officers, and external entities. Write and edit formal reports, assessing and communicating identified findings. Conduct follow-up procedures on findings and report on corrective actions taken. Lead special projects and investigations as requested. Stay abreast of emerging issues and developments in the health insurance industry, particularly in Medicare and the Exchange. Qualifications Pharmacy Operations Oversight Specialist Bachelors degree in a business?related field with 35 years of Medicare Part D/Pharmacy benefit or PBM experience related to eligibility, benefits, and/or claims adjudication. Certified Pharmacy Technician certification preferred. Pharmacy Oversight Specialist Senior Bachelors degree in a business?related field with at least eight years of benefit, PBM, or pharmacy adjudication experience. Certified Pharmacy Technician certification preferred. Skills & Attributes Demonstrated understanding of Medicare Part D and/or insurance products, CMS and state guidance, and PBM claim adjudication systems. Ability to translate compliance concepts into practical operational oversight. Proficiency with Microsoft Office, Access, Visio, and SharePoint. Business analysis and continuous process improvement experience. Strong analytical skills for large data sets and complex requests. Report development and executive summary writing. Knowledge of pharmacy claim analysis and quality practices. Experience with pharmacy claims processing systems, especially RxClaim. Experience with AI tools to enhance productivity and decision?making. Additional Functions for Senior Specialist Create, maintain, and deliver oversight reports and program updates to compliance teams. Compile executive?level summaries of compliance programs. Design oversight programs to target risk areas and mitigate compliance vulnerability. Collaborate with compliance leadership at the plan level. Work Environment Travel required locally or out of state. May be required to work outside of normal hours. Compensation Pharmacy Ops Oversight Specialist: $57,000 - $78,000 annual base, 5% bonus target. Pharmacy Ops Oversight Specialist Senior: $71,000 - $89,000 annual base, 10% bonus target. Why Join Cambia Work alongside diverse teams building cutting?edge solutions to transform health care. Earn a competitive salary and enjoy generous benefits. Grow your career with a company committed to your success. Give back to your community through outreach programs. Engage with employee resource groups and community initiatives. Benefits Medical, dental, vision, and mental health coverage. Health savings account contribution. Paid time off, 10 company?paid holidays, and flexible scheduling. 401(k) with company match. Up to 12 weeks of paid parental leave. Wellness programs and Employee Assistance Program. Commuting and parking benefits. Work from home is available; requires a wired internet connection with minimum 5?Mbps upload and 10?Mbps download speeds. 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. Due to a medical condition or disability, if you need accommodation for any part of the application process, please email CambiaCareers@cambiahealth.com. Privacy policies regarding data collection and disclosure are available here. #J-18808-Ljbffr