Pharmacy Claims Review ManagerAs the
Pharmacy Claims Review Manager your responsibilities will include (but are not limited to):
The Pharmacy Claims Manager is responsible for overseeing all pharmacy claims processing operations, including prescription adjudication, third-party billing, claim rejection management, and reimbursement optimization. This position leads a team responsible for ensuring accurate and timely claim submission, resolution of claim exceptions, compliance with PBM, Medicare Part D, Medicaid, and commercial payer requirements, and adherence to NCPDP standards.
The Pharmacy Claims Manager partners closely with Billing, Customer Accounts, and Pharmacy Operations to ensure accurate reimbursement and compliance, minimize claim write-offs, and ensure exceptional service to residents, facilities, and payers. In our Long-Term Care environment, there is focus on coordination with the Credentialing & Contracting team on payer enrollment issues, and management of LTC-specific reject queues related to transition fills, hospice billing, and facility census changes.
Some benefits may include:- Paid training & career advancement opportunities
- $25,000 toward ongoing education benefit
- Generous Paid Time Off that pools vacation, sick & holiday pay in a single bucket for flexible use
- Medical/Dental/Vision insurance
- Free access to MDLIVE - allowing access to your health benefits from anywhere
- 401K With Employer Match
- Employee Assistance Program: with free access to counseling & support services
Qualifications- Bachelor's degree in Healthcare Administration, Business, Finance, or related field; equivalent experience considered.
- Minimum 5 years of pharmacy claims, third-party billing, pharmacy revenue cycle, or PBM operations experience. Long - Term Care experience preferred.
- Minimum 2 years of supervisory or management experience.
- Strong understanding of: NCPDP claim standards, Medicare Part D, Medicaid pharmacy billing, Managed Care reimbursement, PBM claim adjudication processes, Pharmacy revenue cycle operations.
- Experience working with PBMs such as Express Scripts, CVS Caremark, OptumRx, Humana, Prime Therapeutics, MedImpact, and Navitus.
- Experience managing Medicare Part D, Medicaid, and dual-eligible populations
- Advanced analytical and problem-solving skills.
- Proficiency with pharmacy management systems and reporting tools
- Ability to work under pressure in fast-paced environment ensuring timely and accurate billing
- Ability to travel to other pharmacy locations as required
- Certified Pharmacy Technician (CPhT) preferred (can obtain after hire)
