Massachusetts Jobs

Why This Role is Important to Us:

The Pharmacy Operations Specialist is responsible for supporting the operational functions of Commonwealth Care Alliance (CCA) pharmacy program. Operational functions include: claims oversight and resolution, monthly EOB reviews and monthly formulary and pharmacy directory files review and upload.

This position requires someone who is highly organized, detail-oriented, personable, and able to adapt to a dynamic environment.

What You'll Be Doing:

CLAIMS OVERSIGHT

• Daily reject and paid claims review to ensure proper adjudication

• Daily and monthly transition claims review to ensure proper adjudication, claims messaging occur, and letters sent to members in a timely fashion

• Escalate to pharmacy management and PBM on issues with claims

• Identify systemic issue with configuration

• Resolve issues in a timely manner

FORMULARY MANAGEMENT

• Create, maintain, submit, and post formularies using formulary management tool for all lines of business

• Support pharmacy operations team in the analysis of monthly and yearly formulary submissions.

• Review monthly CDAG reports for timeliness of PAs processed by PBM

EXPLANATION OF BENEFITS (EOBs)

• Monthly review of EOBs to ensure accuracy of information

• Escalate to pharmacy management and PBM when issues are identified

• Identify systemic issue with configuration

• Resolve issues in a timely manner

PHARMACY DIRECTORY

• Monthly review of pharmacy directories to ensure accuracy of data to our external vendor

• Escalate to pharmacy management and external vendors when issues are identified

• Resolve issues in a timely manner

Secondary Duties & Responsibilities:

• Track and formally respond to pharmacy related inquiries from internal and external stakeholders

• Support department initiatives and projects as assigned

• Serve as a resource to others within the department.

What We're Looking For:

Required Education:

• Associate degree in Healthcare, Nursing, Pharmacy or a related area or equivalent experience required

Desired Education:

• Bachelor's degree preferred Certified Pharmacy Technician (CPhT) preferred

Required Experience:

• Experience in retail, hospital, or managed care pharmacy industry required.

• Experience working with Medicare Parts B and D and/or Medicaid Plans preferred.

• 3 years' coding, billing, auditing of healthcare claims, or investigative experience (for a

• Level I position) or 5 years' coding, billing, and auditing of healthcare claims, or investigative experience (for a Level II position)

• Experience working with Medicare Parts B and D and/or Medicaid Plans preferred.

Desired Experience:

• Minimum of 3 years of experience in health care or health insurance industry preferred.

Required Knowledge, Skills & Abilities:

• Proficiency in MS Office: Excel, Word, and PowerPoint required

• MS Visio experience preferred

• Must have excellent oral and written communication skills, including preparation of presentation-ready materials.

• Excellent analytical skills necessary to interpret pharmacy data and reports

• Proven time management and organizational skills.

• Ability to manage multiple tasks, workflows and responsibilities that can vary significantly across business lines

• Capable of working in a fast-paced environment while maintaining accuracy in all elements of the position.

• Must be detail oriented, be able to work independently, and must have solid self-motivation skills.

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.