Job Description
Title: Pharmacy Operations Analyst – Remote
Location: US National
Our mission is to make healthcare right. Together. We are a value-driven healthcare company committed to providing personalized care to aging and underserved populations. We do this by aligning stakeholders across the healthcare ecosystem. Together, we can improve consumer experience, optimize clinical outcomes, and reduce total cost of care.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives apply to join our team.
SCOPE OF ROLE
The Pharmacy Operations Analyst will provide oversight of delegated customer service and coverage determination activities to ensure requests are being handled appropriately. This role will work directly with the PBM in tandem with internal compliance and SIU teams to ensure all fraud, waste, and abuse investigations are executed appropriately. This role will also provide operational support by developing a detailed understanding of the plan’s pharmacy benefits which will be used to assist with identifying and remediating discrepancies and assist with yearly testing efforts.
ROLE RESPONSIBILITIES
Core responsibilities will involve project management, operational management, and materials management. The job description below is intended to point out other responsibilities within the role, but it is not limited to these items.
- Manage pharmacy customer service oversight including quality reviews, metrics, dashboards for reporting, and policy and procedures.
- Provide oversight and assist PBM with fraud, waste, and abuse investigations.
- Provide PBM oversight on non-clinical activities related to coverage determinations and redeterminations.
- Intake, manage, and resolve inquiries, issues, and audits that may come from members, stakeholders, states, CMS and/or any other channel for Bright Health and affiliate plans.
- Assist with claims monitoring and testing of new plan year pharmacy benefit installation for Bright Health and affiliate plans within PBM (Pharmacy Benefit Manager) testing and production system.
- Support the management of project plans, meeting minutes, and any applicable work files for PBM, internal stakeholders, or external vendor initiatives.
- Contribute to the preparation of dashboards and reports that will be used for oversight, management, and leadership reporting for Bright Health and affiliate plans.
- Draft and maintain administrative pharmacy policies related to core job responsibilities.
- Collaboratively work with both clinical and non-clinical areas within Bright Health and affiliate plans.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor’s Degree preferred.
- Five (5) years of experience with call center, triaging and resolving inquiries associated to pharmacy claims and benefits.
- Five (5) years of experience with pharmacy claim adjudication systems, including installing and testing pharmacy benefits.
- Three (3) years of experience in Medicare Advantage.
- Seven (7) years of professional experience in Pharmacy at a health plan or PBM.
- Five (5) years of project management/relationship management experience required, preferably in the pharmacy or healthcare industry preferred.
LICENSURES AND CERTIFICATIONS
- Certified Pharmacy Technician (CPhT) desired but not required.
WORK ENVIRONMENT
- Remote
