Clinical Program Advisor - Express Scripts - Remote (Clinical Configuration)

ESSENTIAL FUNCTIONS

• Work with internal partners to ensure all implications of requested clinical benefit requirements are vetted, understood and communicated as necessary.
• Accountable for timely and accurate translation of client intent into F14 system configuration.
• Track and communicate status of service requests as necessary.
• Assist in remediating process gaps and documenting best practice.
• Intent capture, documentation and client advisor .
• Meet with clients to discuss and clarify clinical benefit requirements.
• Advise clients on the most efficient way to implement intent within F14 systems.
• Understand client's existing clinical benefit and business philosophy to help avoid unnecessary clarifications.
• Analyze new requirement against existing setup.
• Identify interdependent functionalities, programs or areas that may be impacted by the request (i.e. member communications, rebates, finance, networks, etc).
• Consult with team members, SMEs and specialized teams as necessary.
• Provide assistance to team members with issues needing clinical interpretation and guidance.
• Translate requirements as necessary into internal requests/submissions.
• Ensure requests are routed to the appropriate functional areas/specialists.
• Serve as business owners to necessary IT projects that involve clinical benefit.
• Manages and tracks all requests to ensure timelines are met including the proactive management of client specific performance guarantees.
• Responsible for communicating completed benefit notifications to client with documentation of accurate set up.
• Complete random review of work completed by coding teams.
• Periodically monitor claims to ensure the benefit is coded to match client intent.
• Develop a deep understanding of our claims adjudication system and associated clinical applications.
• Identify and help remediate any process gaps, develop and document best practices by creating or modifying existing SOPs, process maps, references and intent forms.
   

QUALIFICATIONS

• Bachelor of Science in Pharmacy; Doctor of Pharmacy and advanced degrees or pharmacy residency preferred

• Current U.S. Pharmacist License, Minimum 3 years licensure recommended

• Current RPh Licensure in good standing as required by the state in which work is performed.
• Microsoft office with a strong understanding of Excel and Access.
• Written and verbal communication (listening, feedback; translating complex ideas/processes), collaboration, analytical thinking/critical thinking, results-oriented and organizational skills.
• In depth understanding of F14 adjudication system and associated clinical applications.
• In depth understanding of operations organizational structure along with roles and responsibilities of departments involved with clinical request types (Tribal Knowledge).

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an annual salary of 95,100 - 158,500 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solu