Pharmacy Ops Oversight Specialist

Pharmacy Ops Oversight Specialist

Work from home within Oregon, Idaho, or 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 Pharmacy Ops Oversight Specialists are living our mission to make health care easier and lives better. As a member of the Pharmacy Operations team, our Pharmacy Ops Oversight Specialists assist in planning, coordinating, conducting, and reporting on pharmacy operations activities carried out by delegated entities which provide Pharmacy Benefit Management services to Cambia’s Medicare Part D, Exchange or commercial portfolio.

Specifically, this job performs oversight of vendors’ delegated responsibilities which may include: Prescription Drug Event (PDE); Coverage Determinations, Appeals, and Grievances (CDAG); Formulary Administration (FA); Refund and Recovery (RR); and other operations oversight functions as assigned. Supports CMS, state, customer audit initiatives by investigating samples, identifying scenarios of concern, researching claims within the pharmacy system, and evaluating reports with a focus on identifying potential gaps in the existing oversight activities.

Do you have a passion for serving others and learning new things? Then this role may be the perfect fit.

What You Bring to Cambia: 

Qualifications:  

The Pharmacy Operations Oversight Specialist would have a Bachelor’s degree in a business related field with at least 3-5 years Medicare Part D/Pharmacy benefit, and/or PBM experience related to eligibility, benefits and/or claims adjudication or equivalent combination of education and experience. Certified Pharmacy Technician certification is preferred.

The Pharmacy Oversight Specialist Senior would have a Bachelor’s degree in a business related field with at least eight years benefit, and/or 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: 

• Demonstrated understanding of practices and requirements related to Medicare Part D and/or Insurance Exchange and Commercial pharmacy products, CMS and State guidance and PBM claim adjudication systems.

• Demonstrated ability to translate compliance concepts into practical operational oversight.

• Demonstrated proficiency with Microsoft office products including Word, Outlook, PowerPoint, Excel, Access, Visio and Sharepoint.

• Experience with business analysis and continuous process improvement.

• Demonstrated ability to analyze large amounts of data and handle complex requests.

• Demonstrated ability to develop reports and executive summary documents.

• Demonstrated knowledge of Pharmacy Claim Analysis and quality practices.

• Demonstrated knowledge of pharmacy claims processing systems, particularly RxClaim.

• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

Additional Skills and Attributes for Pharmacy Oversight Specialist Senior:

• Demonstrated expert understanding of practices and requirements related to Medicare Part D and/or Insurance Exchange and Commercial pharmacy products, CMS, and State guidance and PBM claim adjudication systems.

• Demonstrated expert knowledge of Pharmacy Claim Analysis and quality practices.

• Demonstrated expert knowledge of pharmacy claims processing systems, particularly RxClaim

• Demonstrated ability to identify compliance concerns, recommend solutions, and implement oversight programs to effectively correct them

What You Will Do at Cambia:  

• Contributes to the development and implementation of oversight, monitoring, and audit plan related to Regence’s healthcare providers and other contracted entities.

• Partners with internal departments to ensure that the contracts with Regence’s healthcare providers and other contracted entities include updated and relevant contractual language.

• Requests operations attestations, examines documentation, interviews operations contacts, and performs other procedures necessary to ensure that Regence’s healthcare providers and other contracted entities are meeting operat