About the Role
This role is responsible for managing and resolving escalated pharmacy claims and operational issues, ensuring accurate processing, regulatory compliance, and timely communication with internal teams and external partners.
Responsibilities
- Analyze and resolve high-complexity pharmacy claim disputes and system discrepancies
- Collaborate with pharmacy networks, claims departments, and benefit teams to address resolution barriers
- Ensure pharmacy data accuracy and consistency across claims processing systems
- Respond to member and provider inquiries related to denied or delayed prescriptions
- Support compliance with federal and state pharmacy regulations
- Document resolution steps and outcomes in accordance with audit standards
- Escalate unresolved issues to appropriate departments with detailed case summaries
- Maintain up-to-date knowledge of pharmacy benefit policies and plan designs
- Identify trends in pharmacy claim errors and recommend process improvements
- Participate in cross-functional projects to enhance pharmacy operations
- Verify eligibility and formulary status to support accurate claim adjudication
- Monitor pending cases to ensure timely resolution within service level agreements
- Interpret clinical and administrative data to support resolution decisions
- Assist in training junior staff on resolution protocols and system tools
- Prepare reports on resolution metrics and case volume trends
- Support audit readiness by maintaining accurate and complete case records
- Engage with external pharmacy partners to clarify claim rejections
- Apply critical thinking to resolve ambiguous or non-standard pharmacy scenarios
- Ensure data privacy and confidentiality in all resolution activities
- Utilize multiple software platforms to track, update, and close cases
Compensation
Competitive salary and benefits package offered
Work Arrangement
Hybrid work model available
Team
Part of the pharmacy operations team focused on issue resolution and member support
Work Environment
This role operates in a fast-paced healthcare setting with regular deadlines and high expectations for accuracy. The specialist will use computer systems extensively and interact with internal stakeholders and external partners.
Physical Requirements
Position requires prolonged sitting, frequent computer use, and regular communication via phone and email. Occasional lifting of up to 10 pounds may be necessary.
Not available for this position
