Analyze standard and customized PBM coding requests and work with internal teams to obtain accurate, complete plan documentation needed to code client intent into the pharmacy claim adjudication system in a timely manner.
Implement new and maintain existing client hierarchies, benefit plans, pricing, formularies, and networks in the pharmacy claim adjudication system, consistent with client or company direction and intent.
Maintain formularies and clinical program offerings in the pharmacy claim adjudication system.
Perform pre- and post-implementation claim testing and other configuration quality reviews to ensure accurate claim adjudication and adherence to standard and custom design requirements.
Identify discrepancies, inaccuracies, and unintended consequences, and take corrective action.
Research and respond to claims processing and system configuration inquiries from internal departments.
Proactively identify setup service issues and escalate to Operations Director for immediate review and resolution.
Accurately configure non-adjudicated services and fees across multiple systems.
Support QA and audit staff and functions.
Participate in project management and complete other assigned duties and projects as needed.
Associate degree or equivalent combination of education and job-related experience.
At least 5 years of experience in pharmacy benefits or pharmacy/medical processing.
Strong understanding of pharmacy benefit plans, including copays, out-of-pocket costs, drug coverage, accumulators, pharmacy networks, billing/payment methodologies, formularies, and PBM industry standards.
Prior PBM experience in a benefit configuration or setup role.
Experience in claim testing and quality assurance.
Knowledge of PBM configuration systems.
Strong analytical and problem-solving skills.
Excellent verbal and written communication skills.
Good interpersonal skills and ability to work well with a wide range of people.
Strong organizational and time management skills.
Dependability with good attendance and adherence to timelines and schedules.
Resourcefulness and initiative in project development and completion.
Strong customer service orientation.
Proficiency in MS Office applications.
Health insurance
Dental insurance
Vision insurance
Flexible spending account
Life insurance
Paid time off
401(k)
AD&D insurance
Prescription drug insurance
Bonus pay
Location
N/A
Employment Type
Full-time
Experience Level
Senior
Salary Range
$65,000 - $80,000
Remote work allowed
Yes
Posted
1 month ago