Manager, Pharmacy Claims Reprocessing

What you’ll do

In a few words…

Abarca is igniting a revolution in healthcare.  We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…

The Pharmacy Benefit Manager Operations and Services team provides high quality services to clients and members by running services from clinical programs, pricing, eligibility, configurations, and beneficiary services to government services and beyond. The Darwin Claims Reprocessing team handles all claims reprocessing and adjustments including issue management, Government Programs, and operational requests, as well as related special projects.  

As the Manager for Pharmacy Claims Reprocessing, you will be responsible for overseeing and supervising the Claims Reprocessing team. This role will require time on leadership activities including assigning work via ticketing system, training, coaching, and triaging issues. The manager will also support process improvement initiatives and ensure adherence to department standard desktop procedures. You will oversee the organization and distribution of work related to claims reprocessing and adjustments and serve as the main liaison with other departments and ensure reprocessing requests are completed timely and accurately. 

The fundamentals for the job…

• Oversee the day-to-day work of the claims reprocessing team.
• Provide input and monitor team goals (i.e., Objective Key Results, Key Performance Indicators, and project deliverables) ensuring team is delivering accurate results.
• Responsible for development of team, performance review, growth conversation, and calibration processes.
• Define and maintain standard desktop procedures (SDP) for critical department functions. 
• Define and lead process improvement and special initiatives including product enhancements.
• Ensure daily tasks are adequately distributed between the Lead and team members and are completed towards client satisfaction and complaint with regulatory requirements and service level agreements. 
• Mentor and provide feedback to ensure team members consistently deliver quality and well-timed results in partnership with stakeholders. 
• Represent the team in client calls and collaborates with peers for second tier consults.
• Develop and deliver progress status reports and hold regular status meetings with team.

What we expect of you

The bold requirements… 

• Bachelor’s or Master’s degree in Engineering, Computer, Healthcare, Business, or related field. (In lieu of a degree, equivalent, relevant work experience may be considered.)
• 8+ years of experience in Pharmacy Claims Operations, including 4+ years of supervisory experience.
• Experience applying analytical and troubleshooting skills to claims administration operations.
• Experience working with SQL and Excel tools.
• Experience establishing rapport with internal operational teams as well as stakeholders and clients via interpersonal skills.
• Excellent oral and written communication skills.
• We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only) 

Nice to haves…

• Experience with Healthcare, Pharmacy Network, and Pharmacy Benefit Management industries, Medicaid/Medicare Part D, and CMS regulations.

Physical requirements… 

• Must be able to access and navigate each department at the organization’s facilities. 
• Sedentary work that primarily involves sitting/standing. 

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves.  We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify.  “Applicant must be a United States’ citizen. Abarca Health LLC does not sponsor employment visas at this time”

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.

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