Pharmacy Operations Oversight specialist OR SR
Remote within only ID, OR, UT, WA
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.
Additional Minimum Responsibilities for Pharmacy Operations Oversight Specialist Senior:
- 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.
Additional Minimum Requirements for the Pharmacy Operations Oversight Specialist Senior:
- 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.
Normally to be proficient in the competencies listed above
- 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 Pharmacy Operations Oversight Specialist would have a Bachelor's degree in a business related field with at least 3-5 years Medicare Part D/Pharmacy benefit, and/or PBM experience related to eligibility, benefits and/or claims adjudication or equivalent combination of education and experience. Certified Pharmacy Technician certification is preferred
The Pharmacy Oversight Specialist Senior would have a Bachelor's degree in a business related field with at least eight years benefit, and/or PBM experience related to eligibility, benefits and/or claims adjudication or equivalent combination of education and experience. Certified Pharmacy Technician certification is preferred
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
This position includes 401(k), healthcare, paid time off, paid holidays, and more. For more information, please visit www.cambiahealth.com/careers/total-rewards
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 drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com