Pharmacy Ops Oversight Specialist Sr
Cambia Health Solutions

Job Info

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Pharmacy Ops Oversight Specialist SR

Telecommute Option - Must reside in ID, OR, UT or WA

WHO WE NEED

Assists in planning, coordinating, conducting, and reporting on pharmacy operations activities carried out by delegated entities which provide Pharmacy Benefit Management services to Cambia's Medicare Part D, Exchange or commercial portfolio. Specifically, this job performs oversight of vendors' delegated responsibilities which may include: Prescription Drug Event (PDE); Coverage Determinations, Appeals, and Grievances (CDAG); Formulary Administration (FA); Refund and Recovery (RR); and other operations oversight functions as assigned. Supports CMS, state, customer audit initiatives by investigating samples, identifying scenarios of concern, researching claims within the pharmacy system, and evaluating reports with a focus on identifying potential gaps in the existing oversight activities.

Normally to be proficient in the competencies listed below

The Pharmacy Oversight Specialist Senior would have

• Bachelor's degree in a business related field
  
• At least eight years benefit, and/or PBM experience related to eligibility, benefits and/or claims adjudication
  
• Or equivalent combination of education and experience.
  

Preferred Key Experience:

• Previous PBM or Pharmacy Manage Care Experience
  
• Experience with state/federal rules and regulations
  
• Experience with auditing
  
• Experience/knowledge with Pharmacy claims processing
  

YOUR ROLE:

• Contributes to the development and implementation of oversight, monitoring, and audit plan related to Regence's healthcare providers and other contracted entities.
  
• Partners with internal departments to ensure that the contracts with Regence's healthcare providers and other contracted entities include updated and relevant contractual language.
  
• Requests operations attestations, examines documentation, interviews operations contacts, and performs other procedures necessary to ensure that Regence's healthcare providers and other contracted entities are meeting operations expectations.
  
• Clearly and concisely documents work performed ensuring Regence's service providers and other contracted entities are compliant with applicable CMS or other regulatory requirements.
  
• Develops written findings with respect to non-operations with regulations.
  
• Coordinates operations monitoring efforts with office managers, operations officers, and high-level external entities.
  
• Writes and/or edits formal reports; assesses and communicates identified findings.
  
• Conducts and documents follow-up procedures on findings and reports on the status of corrective action taken.
  
• Conducts special projects and investigations as requested.
  
• Keeps abreast of emerging issues and developments in the health insurance industry especially as it relates to Medicare or the Exchange.
  
• Create, maintain, and deliver oversight reports and program updates to compliance teams within the company and at the client.
  
• Compile executive-level summaries of compliance programs and deliver as needed.
  
• Design oversight programs to achieve desired results, target areas of risk, and mitigate compliance vulnerability for the plans.
  
• Work closely with compliance leadership at the plans at a strategic level to ensure that oversight programs effectively deliver desired results to the client.
  

WHAT YOU BRING:

• Demonstrated understanding of practices and requirements related to Medicare Part D and/or Insurance Exchange and Commercial pharmacy products, CMS and State guidance and PBM claim adjudication systems.
  
• Demonstrated ability to translate compliance concepts into practical operational oversight.
  
• Demonstrated proficiency with Microsoft office products including Word, Outlook, PowerPoint, Excel, Access, Visio and Sharepoint.
  
• Experience with business analysis and continuous process improvement.
  
• Demonstrated ability to analyze large amounts of data and handle complex requests.
  
• Demonstrated ability to develop reports and executive summary documents.
  
• Demonstrated knowledge of Pharmacy Claim Analysis and quality practices.
  
• Demonstrated knowledge of pharmacy claims processing systems, particularly RxClaim.
  
• Demonstrated proficiency with either SAS or SQL and Oracle/SQL including ability to write queries based on business need.
  
• Demonstrated expert understanding of practices and requirements related to Medicare Part D and/or Insurance Exchange and Commercial pharmacy products, CMS, and State guidance and PBM claim adjudication systems.
  
• Demonstrated expert knowledge of Pharmacy Claim Analysis and quality practices.
  
• Demonstrated expert knowledge of pharmacy claims processing systems, particularly RxClaim
  
• Demonstrated ability to identify compliance concerns, recommend solutions, and implement oversight programs to effectively correct them
  

The base pay annual salary range is: 63k-108.5k

The bonus target for this position is 10%

At Cambia, we take a variety of factors into account when creating a job offer, including your skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. While we offer competitive salaries, in general, we rarely hire candidates at or near the top of the salary range.

Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:

• medical, dental, and vision coverage for employees and their eligible family members
  
• annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
  
• paid time off and company holidays
  
• up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
  
• up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
  
• one-time furniture and equipment allowance for employees working from home
  
• up to $225 in Amazon gift cards for participating in various well-being activities for a complete list see our External Total Rewards page.
  

We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and 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. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site.

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