Pharmacy Benefits Operations Specialist - Remote

Summary of Job

Support eligibility and benefits configuration and deployment, including collaboration with pharmacy benefits manager (PBM) and Cognizant, formulary teams, for configuration.  Responsible for Quality Assurance and Testing for operations and implementations.  Coordinate and manage the pharmacy plan/ benefit design implementation process in partnership with PBM to ensure the accuracy and timeliness of members’ pharmacy benefit administration for superior member experience.  

Responsibilities

• Maintain in-depth understanding of and ability to create and maintain plan/benefit design rules and limitations to include: Adjudication rules, Clinical rules, Payment rules, and Plan/group management.
   
• Partner with Sales and Product teams, assist in developing pharmacy benefit plan designs, meeting client requests, Health Plan strategic/ business parameters and all regulatory and other oversight agencies’ requirements. 
   
• Responsible for creating and maintaining plan/benefit design documentation to support internal and external requirements 
   
• Lead communication and coordination between Health Plan and PBM for receipt of required information for claims adjudication system set up, reporting and claim adjudication process.
   
• Assess all requests for new/ changes to plan benefit information to ensure compatibility with PBM claim adjudication logic.
   
• Submit accurate and complete requests to the PBM for new and changing benefit plan designs.
   
• Test pharmacy benefit plan designs for accuracy and alignment with business requirements. 
   
• Serve as liaison to PBM to troubleshoot and resolve benefit-related questions/ issues, researching plan/benefit design options and requirements. 
   
• Participate in PBM implementation meetings as required.
   
• Review and approve PBM benefit set up requirements.
   
• Perform claim testing to ensure accurate claim adjudication.
   
• Work with the pharmacy clinical team to implement formulary updates in the claim adjudication system. 
   
• Participate in the research and resolution of claims adjudication-related discrepancies, errors, and problems. 
   
• Acts as a resource to operational areas in support of the pharmacy claims adjudication process and responding to issues related to plan/ benefit design. 
   
• Conduct quarterly audits of pharmacy benefit configurations to ensure alignment with plan design, regulatory requirements, and accurate claim adjudication across all lines of business.
   
• Recommend streamlined work processes and systems that impact plan/ benefit design to create efficiency and quality outcomes. 
   
• Maintain acceptable and appropriate quality levels and production SLA response time.
   
• Perform other projects and duties as assigned