Claims Operations Manager Jobs in Springfield, IL

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The Specialty Pharmacy Manager is accountable for the overall management, oversight, and operation of the outpatient specialty pharmacy program. This role is responsible for ensuring exceptional patient care, regulatory compliance, operational excellence, and financial performance.

Primary Responsibilities:

• Provide compliant and efficient outpatient pharmacy operations with a focus on:
  • Patient Safety
  • Pharmacy Professional Practice
  • Regulatory Compliance
  • Quality Assurance
  • Customer Service
  • Personnel Management
  • Inventory Management
  • Financial Performance
  • Loss Prevention
  • Workflow Optimization
• Educate providers, clinic staff, and patients regarding specialty pharmacy services and medication therapies
• Serve as a clinical resource by addressing medication-related questions and appropriately triaging patient concerns
• Collaborate with providers to support medication adherence, optimize therapy outcomes, and improve patient care
• Partner with clinic leadership and staff to promote specialty pharmacy services and demonstrate the value of the pharmacy care model
• Assist with the recruitment, onboarding, training, and development of Pharmacy Liaisons and Pharmacists
• Maintain compliance with all applicable state and federal regulations, accreditation standards, and company policies
• Provide leadership, coaching, and guidance to pharmacy staff to ensure operational excellence and high-quality patient care
• Monitor pharmacy performance metrics and identify opportunities for process improvement and enhanced patient outcomes

Operational and Oversight Responsibilities

• Partner with site leadership to develop and implement best-in-class dispensing, fulfillment, and shipping protocols designed to maximize patient outcomes
• Assess medication regimens and recommend cost-effective treatment options that support both clinical outcomes and patient affordability
• Collaborate in the development and delivery of training materials to support onboarding and ongoing staff education
• Ensure compliance with specialty pharmacy accreditation standards, including URAC, ACHC, and applicable regulatory requirements
• Oversee pharmacy workflow to ensure timely and accurate dispensing and delivery of medications
• Support inventory management initiatives to maintain appropriate medication supplies while minimizing waste and financial loss
• Contribute to the development, implementation, and revision of pharmacy policies and procedures

Clinical and Regulatory Responsibilities

• Perform order entry and prescription verification within pharmacy management systems, including dispensing and point-of-sale platforms
• Ensure accurate adjudication of prescription claims and resolution of reimbursement issues as needed
• Verify specialty medication delivery methods are appropriate based on patient needs and medication requirements
• Perform comprehensive clinical reviews of prescriptions, including: 
  • Dosage appropriateness
  • Indication review
  • Drug interactions
  • Renal and hepatic dose adjustments
  • Therapeutic appropriateness
• Maintain professional competency through continuing education and professional development activities
• Ensure all activities comply with accreditation standards, legal requirements, and pharmacy regulations

Leadership Responsibilities

• Lead, mentor, and develop pharmacy staff to promote a culture of accountability, collaboration, and continuous improvement
• Assist with workforce planning, employee engagement, and succession planning initiatives
• Partner with organizational leadership to achieve operational, clinical, and financial goals
• Foster solid working relationships with providers, clinic staff, patients, and external partners

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• PharmD from an ACPE-accredited College of Pharmacy; Bachelor's Degree in Pharmacy with relevant pharmacist experience will be considered
• Active pharmacist license in the State of Illinois
• Leadership, supervisory, or management experience in a pharmacy or healthcare setting
• Solid knowledge of pharmacy regulations, medication management, and clinical pharmacy practice

Preferred Qualifications:

• Specialty Pharmacy Manager or Pharmacy Manager experience 
• Specialty pharmacy experience and knowledge of accreditation standards (URAC, ACHC, etc.)
• Experience managing pharmacy operations, workflow, and performance metrics
• Proficiency with Microsoft Office applications and EMR systems, including Epic. 
• Demonstrated solid leadership, communication, and relationship-building skills.
• Demonstrated ability to collaborate effectively with providers, clinic leadership, and cross-functional teams
• Demonstrated ability to manage multiple priorities across specialty pharmacy service lines

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $112,700 - $193,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.