Job Details

Summary of Job

Responsible to support Systems Operations leadership, responsible providing guidance and execution support for eligibility and benefits implementation and management. Lead client benefit review and validation, including copay structures, prior authorization rules, and exclusions. Translate implementations with clear understanding by vendors. Responsible for Quality Assurance and oversight of benefit and eligibility configuration and management. Responsible for managing pharmacy subrogation oversight. Supervise Pharmacy System Specialists and act as liaison between Emblem Health and the Pharmacy Benefit Manager (PBM). Serve as technical and business content expert to develop and manage processes and data to ensure the accuracy and timeliness of members' pharmacy benefit administration driving towards a great member experience. Perform a leading role in identifying and remediating member or employer group discrepancies including benefit setup issues. Supervise the Commercial and HIX plan implementation process

Responsibilities

• Responsible for creating and maintaining plan/benefit design documentation to support internal and external requirements.
• Establish and maintain acceptable and appropriate quality levels and production SLA response times for the Pharmacy systems specialist team.
• Supervise the Pharmacy System Specialist team with communication and coordination between the Health Plan and PBM for receipt of required information for pharmacy benefit set up, reporting, and claim adjudication process.
• Implement and monitor pharmacy benefit installation and testing across the under the direction Pharmacy Ops & Management Director to meet clinical objectives, control costs, and monitor pharmacy vendor performance.
• Implement plans for testing of claim and accumulators in the PBM and Health Plan test environment.
• Conduct testing and validation analysis of claim testing results for product changes, accumulator changes and other system changes as they occur.
• Serve as liaison to PBM to troubleshoot and resolve claim adjudication related questions/ issues; research plan / benefit design interface, new data exchange options and requirements.
• Participate in PBM implementation meetings as required.
• Lead communication and coordination between EmblemHealth and PBM for receipt of required information for claims adjudication system set up, reporting and claim adjudication process.
• Assess requests for new/changes to plan benefit information to ensure compatibility w/PBM claim adjudication logic.
• Supervise the submission of accurate and complete requests to the PBM for new and changing benefit plan designs.
• 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 state mandated benefit set up requirements.
• Work with pharmacy clinical team to implement formulary updates in the claim adjudication system.
• Responsible for creating/maintaining desk level procedures and service level dashboards for business functions to ensure consistent member experience and audit readiness.
• Perform quarterly audits on benefit setup for our top clients to ensure benefit setup accuracy.
• Act as a resource to Health Plan operational areas in support of the pharmacy claims adjudication process and respond to issues related to plan / benefit design.
• Streamline work processes and system modifications that impact plan / benefit design to create efficiency and quality outcomes

• Bachelor's degree.
• 4 - 6+ years of relevant, professional work experience, preferably in a call center environment (Required)
• Additional years of related experience may be considered in lieu of Degree (Required)
• Experience managing staff, initiating, and carrying out programs and projects (required)
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required)
• Knowledge of Pharmacy, Managed Care and Self-Insured healthcare products (Preferred)
• Ability to prioritize tasks daily and trouble shoot urgent customer issues to successful completion (Required)
• Advanced knowledge of Microsoft Office applications - Word, Excel, PowerPoint, Outlook, Teams (Required)
• Meticulous attention to detail; exceptional analytical and problem-solving skills to resolve issues within Operations (Required)
• Ability to make sound decisions in a timely and independent manner (Required)
• Ability to organize, prioritize, and effectively manage multiple tasks/projects simultaneously (Required)