Pharmacy Operations Oversight Specialist or Pharmacy Operations Oversight Specialist Sr. - DOE - Cambia Health Solutions, Inc

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Who We Are Looking For:

Every day, Cambia's dedicated team of Pharmacy Ops Specialists are living our mission to make health care easier and lives better.

As a member of the Pharmacy team our Pharmacy Oversight Specialists help us oversee pharmacy operations activities carried out by our delegated entities. This includes planning, coordinating, and reporting on activities such as Prescription Drug Event (PDE) management, Coverage Determinations, Appeals, and Grievances (CDAG), Formulary Administration (FA), and Refund and Recovery (RR). You'll also support audit initiatives by investigating samples, identifying areas of concern, and evaluating reports to identify potential gaps in our oversight activities. Your work will help us ensure compliance with CMS, state, and customer requirements, and drive continuous improvement in our pharmacy operations. All in service of creating a person-focused health care experience making our members health journeys easier.

What You Bring to Cambia:

Qualifications:

Pharmacy Operations Oversight Specialist -

• Preferred Bachelor's degree in a business related field with at least 3-5 years Medicare Part D/Pharmacy benefit PBM experience related to eligibility, benefits and/or claims adjudication or equivalent combination of education and experience.

• Certified Pharmacy Technician certification is preferred

Pharmacy Operations Oversight Specialist Senior -

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

• Certified Pharmacy Technician certification is preferred

Skills and Attributes:

• Pharmacy Operations Expertise: You've got a solid understanding of Medicare Part D, Insurance Exchange, and Commercial pharmacy products, as well as CMS and State guidance and PBM claim adjudication systems.

• Compliance and Operational Oversight: You can translate compliance concepts into practical operational oversight, and you're proficient in Microsoft Office products, including Word, Outlook, PowerPoint, Excel, Access, Visio, and SharePoint.

• Data Analysis and Reporting: You're skilled at analyzing large amounts of data, handling complex requests, and developing reports and executive summary documents. You're also familiar with Pharmacy Claim Analysis and quality practices.

• Technical Skills: You've got experience with business analysis and continuous process improvement.

• Pharmacy Claims Processing: You've got knowledge of pharmacy claims processing systems, particularly RxClaim, and you're able to apply your expertise to drive process improvements and ensure compliance with regulatory requirements.

What You Will do at Cambia:

• Oversight and Monitoring: You'll contribute to the development and implementation of oversight, monitoring, and audit plans for Regence's healthcare providers and contracted entities.

• Contract Management: You'll partner with internal departments to ensure that contracts with healthcare providers and contracted entities include updated and relevant contractual language.

• Compliance Auditing: You'll conduct audits and examinations to ensure that healthcare providers and contracted entities are meeting operations expectations and complying with regulatory requirements.

• Documentation and Reporting: You'll clearly and concisely document your work, including writing formal reports and assessing identified findings.

• Coordination and Communication: You'll coordinate monitoring efforts with office managers, operations officers, and external entities, and communicate findings and recommendations to stakeholders.

• Corrective Action and Follow-up: You'll conduct follow-up procedures on findings and report on the status of corrective action taken, and conduct special projects and investigations as requested.

• Industry Knowledge and Staying Current: You'll stay up-to-date on emerging issues and developments in the health insurance industry, particularly as it relates to Medicare or the Exchange.

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