Pharmacy Benefit Manager Operations Analyst/Coder

ESSENTIAL JOB FUNCTIONS:

Analyze standard and customized PBM coding requests and work with internal teams to obtain accurate and complete plan documentation needed to code client intent into the pharmacy claim adjudication system in a timely manner

Implement new and maintain existing client hierarchies, benefit plans, pricing, formularies, and networks in the pharmacy claim adjudication system, consistent with the direction and intent set forth by the client or MaxCare

Maintain the MaxCare formularies and clinical program offerings in the pharmacy claim adjudication system

Perform pre- and post-implementation claim testing and other configuration quality reviews to ensure accurate claim adjudication and adherence to standard and custom design requirements

Identify discrepancies, inaccuracies, and unintended consequences, and take corrective action

Research and respond to claims processing and system configuration inquiries from internal departments

Proactively identify setup service issues and escalate to Operations Director for immediate review and resolution

Accurately configure non-adjudicated services and fees across multiple systems

Support QA and Audit staff and functions

Project Management

ADDITIONAL RESPONSIBILITIES

Perform other duties and projects as required by management

Complete department or corporate projects as assigned

MINIMUM QUALIFICATIONS FOR CONSIDERATION:

Associates degree or equivalent combination of education and job-related experience.

Requires at least 5 years of experience in pharmacy benefits or pharmacy/medical processing experience.

Strong understanding of pharmacy benefit plans including copays and out-of-pockets, drug coverage, accumulators, pharmacy network, billing/payment methodologies, formulary, and PBM industry standards

Prior PBM experience in a benefit configuration/setup role.

Experience in claim testing and quality assurance.

Knowledge of PBM configuration system(s)

KNOWLEDGE, SKILLS, AND ABILITIES:

Strong follow-through on projects and deliverables.

Strong analytical and problem-solving skills.

Excellent verbal and written communication skills.

Good interpersonal skills: able to work well with a wide range of people.

Strong organizational and time management skills.

Demonstrate dependability through good attendance and adherence to timelines and schedules.

Demonstrate resourcefulness and ability to take initiative in development and completion of projects.

Strong sense of customer service.

Strong proficiency in MS Office applications.

Job Type: Full-time

Benefits:

• Health insurance
• Dental insurance
• Vision insurance
• Flexible spending account
• Life insurance
• Paid time off

Schedule:

• Monday to Friday

Supplemental Pay:

• Bonus pay

Application Question(s):

• Do you have standard and custom system coding, maintenance, and quality assurance experience in a pharmacy claim adjudication system? We are seeking an individual with direct experience related to standard and custom plan designs, pricing, clinical programs, and pharmacy networks.

Experience:

• Pharmacy Benefits Management: 5 years (Required)

Work Location: Remote or Hybrid

Pay: $65,000.00 - $80,000.00 per year

Benefits:

• 401(k)
• AD&D insurance
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Prescription drug insurance
• Vision insurance

Work Location: Hybrid remote in Oklahoma City, OK 73114