Pharmacy Operations Oversight Specialist Pharmacy Operations Oversight Specialist SR. DOE Work from home in Oregon, Idaho, Utah
Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.
Who We Are Looking For:
Every day, Cambia's dedicated team of Community Health Workers are living our mission to make health care easier and lives better.
As a member of the Pharmacy team our Pharmacy Oversight Specialists help us oversee pharmacy operations activities carried out by our delegated entities. This includes planning, coordinating, and reporting on activities such as Prescription Drug Event (PDE) management, Coverage Determinations, Appeals, and Grievances (CDAG), Formulary Administration (FA), and Refund and Recovery (RR). You'll also support audit initiatives by investigating samples, identifying areas of concern, and evaluating reports to identify potential gaps in our oversight activities. Your work will help us ensure compliance with CMS, state, and customer requirements, and drive continuous improvement in our pharmacy operations. All in service of creating a person-focused health care experience making our members health journeys easier.
What You Bring to Cambia:
Qualifications:
Pharmacy Operations Oversight Specialist -
Preferred Bachelor's degree in a business related field with at least 3-5 years Medicare Part D/Pharmacy benefit PBM experience related to eligibility, benefits and/or claims adjudication or equivalent combination of education and experience.
Certified Pharmacy Technician certification is preferred
Pharmacy Operations Oversight Specialist Senior -
Bachelor's degree in a business related field with at least eight years benefit PBM experience related to eligibility, benefits and/or claims adjudication or equivalent combination of education and experience
Certified Pharmacy Technician certification is preferred
Skills and Attributes:
Pharmacy Operations Expertise: You've got a solid understanding of Medicare Part D, Insurance Exchange, and Commercial pharmacy products, as well as CMS and State guidance and PBM claim adjudication systems.
Compliance and Operational Oversight: You can translate compliance concepts into practical operational oversight, and you're proficient in Microsoft Office products, including Word, Outlook, PowerPoint, Excel, Access, Visio, and SharePoint.
Data Analysis and Reporting: You're skilled at analyzing large amounts of data, handling complex requests, and developing reports and executive summary documents. You're also familiar with Pharmacy Claim Analysis and quality practices.
Technical Skills: You've got experience with business analysis and continuous process improvement.
Pharmacy Claims Processing: You've got knowledge of pharmacy claims processing systems, particularly RxClaim, and you're able to apply your expertise to drive process improvements and ensure compliance with regulatory requirements.
What You Will do at Cambia:
Oversight and Monitoring: You'll contribute to the development and implementation of oversight, monitoring, and audit plans for Regence's healthcare providers and contracted entities.
Contract Management: You'll partner with internal departments to ensure that contracts with healthcare providers and contracted entities include updated and relevant contractual language.
Compliance Auditing: You'll conduct audits and examinations to ensure that healthcare providers and contracted entities are meeting operations expectations and complying with regulatory requirements.
Documentation and Reporting: You'll clearly and concisely document your work, including writing formal reports and assessing identified findings.
Coordination and Communication: You'll coordinate monitoring efforts with office managers, operations officers, and external entities, and communicate findings and recommendations to stakeholders.
Corrective Action and Follow-up: You'll conduct follow-up procedures on findings and report on the status of corrective action taken, and conduct special projects and investigations as requested.
Industry Knowledge and Staying Current: You'll stay up-to-date on emerging issues and developments in the health insurance industry, particularly as it relates to Medicare or the Exchange.
#LI-remote
The expected hiring salary range for a Pharmacy Operations Oversight Specialist is $62,000 - $78,000 a year depending on skills, experience, education, and training; relevant licensure / certifications; and performance history.
The current full salary range for Pharmacy Operations Oversight Specialist is $57,000 - $94,000 a year.
The bonus target for Pharmacy Operations Oversight Specialist is 5%.
The expected hiring range for a Pharmacy Operations Oversight Specialist Senior is $74000 - $85,000 a year depending on skills, experience, education, and training; relevant licensure / certifications; and performance history.
The current full salary range for Pharmacy Operations Oversight Specialist Senior is $70,000 - $115,000 a year.
The bonus target for Pharmacy Operations Oversight Specialist Senior is 10%.
About Cambia
Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.
Why Join the Cambia Team?
At Cambia, you can:
Work alongside diverse teams building cutting-edge solutions to transform health care.
Earn a competitive salary and enjoy generous benefits while doing work that changes lives.
Grow your career with a company committed to helping you succeed.
Give back to your community by participating in Cambia-supported outreach programs.
Connect with colleagues who share similar interests and backgrounds through our employee resource groups.
We believe a career at Cambia is more than just a paycheck - and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.
In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include:
Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
Annual employer contribution to a health savings account.
Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
Award-winning wellness programs that reward you for participation.
Employee Assistance Fund for those in need.
Commute and parking benefits.
Learn more about our benefits.
We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.
