Job Overview
We are seeking a detail-oriented PBM Plan Design Analyst to join our team. In this role, you will be responsible for evaluating and coding PBM programs and edits, ensuring compliance with industry standards, and providing support to various operational issues and projects. The ideal candidate will possess strong analytical and operational skills and a solid understanding of PBM administration.
Duties
- Analyze standard and customized PBM coding requests and work with internal teams to obtain accurate and complete plan documentation needed to code client intent into the pharmacy claim adjudication system in a timely manner
- Implement new and maintain existing client hierarchies, benefit plans, pricing, formularies, and networks in the pharmacy claim adjudication system, consistent with the direction and intent set forth by the client or MaxCare
- Maintain the MaxCare formularies and clinical program offerings in the pharmacy claim adjudication system
- Perform pre- and post-implementation claim testing and other configuration quality reviews to ensure accurate claim adjudication and adherence to standard and custom design requirements
- Identify discrepancies, inaccuracies, and unintended consequences, and take corrective action
- Research and respond to claims processing and system configuration inquiries from internal departments
- Proactively identify setup service issues and escalate to Operations Director for immediate review and resolution
- Accurately configure non-adjudicated services and fees across multiple systems
- Support QA and Audit staff and functions
- Perform other duties and projects as required by management
- Complete department or corporate projects as assigned
Skills
- Proficiency in PBM administration software and Microsoft Office Suite.
- Strong analytical skills with the ability to interpret complex data and make informed decisions.
- Excellent communication skills, both written and verbal, for effective interaction with clients, peers, and management.
- Detail-oriented with strong organizational skills to manage multiple projects simultaneously.
- Ability to work collaboratively in a team environment while also being self-motivated.
Minimum Qualifications
- Requires at least 5 years of experience in pharmacy benefits or pharmacy/medical processing experience.
- Strong understanding of pharmacy benefit plans including copays and out-of-pockets, drug coverage, accumulators, pharmacy network, billing/payment methodologies, formulary, and PBM industry standards
- Prior PBM experience in a benefit configuration/setup role.
- Experience in claim testing and quality assurance.
- Knowledge of PBM configuration system(s)
Join our dynamic team as a Plan Design Analyst where you will play a crucial role in enhancing our client experience through effective and transparent pharmacy benefits management!
Job Type: Full-time
Pay: $60,000.00 - $80,000.00 per year
Benefits:
- Dental insurance
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Vision insurance
Application Question(s):
- Do you have at least 5 years of PBM operations experience?
Work Location: Remote
