SUMMARY:
This role is responsible for managing the overall operational activities within the Pharmacy Benefits Operations team. This includes the functional areas of Claims Reviews, PDE Monitoring, Grievances, Plan Configuration Testing, file transfer oversight, COB/ Underpaid Claim Recoveries, and issue management as related to the PBM. The Senior Manager, Pharmacy Benefits Operations is responsible for developing the necessary process flows, procedures and infrastructure to maintain a highly efficient operational model which is scalable to support near-term and long-term future growth. The role is responsible for coordinating activity with all internal departments including vendor management, space planning, emergency preparedness, business continuity, IT, Human Resources, Compliance, Network Management and Medical Management.
RESPONSIBILITIES/TASKS:
* Identifies, develops, implements and manages all necessary operational processes for each functional area, including but not limited to:
* Claims monitoring
* PDE monitoring
* Oversight of PBM SLAs
* Grievances
* Member collections for underpaid claims
* Oversight of member communications such as TLs, EOBs, etc.
* FIR rejects and aging
* Works with the technology team to identify Business requirements to ensure that the Technology solutions meet internal departmental and external client needs
* Responsible for balancing workload to optimize the effectiveness of the department
* Represents PBM Operations in enterprise-wide and client facing projects
* Participates and provides subject matter expertise in all PBM client implementation projects
* Perform or source project management duties as necessary
* Develops and manages all system access requests related to client needs
* Acts as the lead to represent PBM Operations in the Governance planning meetings
* Serves on the Annual AEP planning committee to ensure all PBM operational needs are met
DIRECTION EXERCISED:
Directly supervises exempt and non-exempt staff in accordance with company policies and applicable Federal and State Laws. Responsibilities include but are not limited to effectively interviewing, hiring, terminating, and training employees; planning, assigning and directing work; appraising performance; rewarding and counseling employees; addressing complaints and resolving problems; supporting and encouraging the engagement process. Exercises significant autonomy in executing position duties.
EMPLOYMENT QUALIFICATIONS:
EDUCATION:
Bachelor's degree in Business Administration, Finance, or related field. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company's learning philosophy, is required.
EXPERIENCE:
Seven to ten years' experience in a PBM operations environment with five years' experience in pharmacy Medicare operations. Demonstrated technical experience that provides the necessary knowledge, skills and abilities.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
* Experience/knowledge in the following pharmacy areas is required:
* Claims operations and analysis
* Benefit design and adjudication platform configuration
* Eligibility functions
* PDE operations and reconciliation
* Experience/knowledge in the following pharmacy areas is preferred:
* FIR operations and reconciliation
* Pharmacy member communications
* Grievance processing
* Plan finder operations
* Account management
* Demonstrated understanding of CMS guidance surrounding Medicare Part D
* Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management
* Ability to work with and empower others on a collaborative basis to ensure success of the team
* Ability to operate successfully in a matrixed environment, utilizing influence to achieve desired outcomes.
* Ability to effectively interface with clients and vendors in person, on the phone, and via written communication.
* Ability to effectively exchange information, in verbal or written form, by sharing ideas, reporting facts and other information, responding to questions and employing active listening techniques
* Ability to establish workflows, manages multiple projects, and meets necessary deadlines
* Knowledge and experience in organizational effectiveness and operations management
* Knowledge of business and management principles and practices
* Knowledge of project management principles and practices
* Information technology skills
WORKING CONDITIONS:
Work is performed in an office/home office setting with no unusual hazards. Ability to travel as required. Travel is estimated to not exceed 25% of the time.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.
