Manager of Plan Benefit Administration
MaxCareRx Edmond, OK
- Posted: over a month ago
- Benefits: medical, vision, 401k, dental, life insurance
JOB SUMMARY: Serves as MaxCare business owner of claims adjudication processes, establishes, maintain and champions adjudication practices, business applications, operating guidelines and business rules. As necessary, simplifies and redesigns adjudication processes (including recommend technology improvements). The primary functions of this position involve ensuring MaxCare versatile adjudication system allows for various benefit designs, accurate eligibility, implementation and maintenance.
ESSENTIAL JOB FUNCTIONS:
- Works closely with the Benefits Systems Analysts and Quality Auditors for implementation of pharmacy initiatives through claims processing system.
- Creates and prepares a written analysis and action plans of testing/auditing results.
- Analyze standard and customized timely coding request and work with internal departments to obtain accurate and complete plan documentation for claims processing system.
- Maintains past implementation practices and database for future audit and review.
- Ensures auditing processes and practices meet all pharmacy related regulatory and client contractual requirements.
- Perform pre-and post-implementation claim testing and other configuration quality reviews to strategize adherence to standard and custom design requirements.
- Maintain and review training materials to provide specific instructions and process flows of how to operate in current adjudication system.
- Assist in identifying root causes of processes that are not meeting quality standards and implement improvement plans.
- Perform other duties and projects as required by management.
- Complete department of corporate projects as assigned
MINIMUM QUALIFICATIONS FOR CONSIDERATION:
- Bachelor’s degree in Business Management or other related field required.
- At least 5 years of experience in Pharmacy Benefits or Pharmacy/medical processing experience
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
PREFERRED EDUCATION AND EXPERIENCE
- Prior PBM experience in a benefit configuration role
- Certified Pharmacy Technician (CPhT) certification
- Knowledge of RxClaim or other PBM configuration systems
- Experience in testing and quality assurance
KNOWLEDGE, SKILLS, AND ABILITIES:
- Must be detailed oriented and highly organized
- Accurately analyze and interpret common employee benefit terminology
- Ability to work independently and make professional decisions
- Excellent verbal and written communication skills, including but not limited to review of daily training and operations tasks.
- Good interpersonal skills: able to work well with a wide range of people.
- Capable to handle multiple tasks simultaneously.
- Strong organizational and time management skills.
- Demonstrate dependability through good attendance and adherence to timelines and schedules.
- Excellent follow through on projects and deliverables.
- Strong analytical skills.
- Strong problem-solving skills.
- Demonstrate resourcefulness and ability to take initiative in development and completion of projects.
- Strong sense of customer service.
- Strong work ethic characterized by high integrity and professionalism.
- Strong proficiency in pc applications including but not limited to Excel, PowerPoint, & Word.
- SQL skills
- New product development
This work is sedentary and requires the following physical activities:
- Sitting for long periods of time; occasional bending, squatting, kneeling, stooping; good finger dexterity and feeling; frequent repetitive motions; talking, hearing, and visual acuity.
- Frequent lifting (up to 10 pounds of paper supplies or minor office equipment).
- Driving to client locations and other sites as needed.
- Normal office environment.
NOTE: The above statements are intended to describe the general nature and level of work performed by an employee in this position. These statements are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of employees in this position.
MaxCareRxWhy Work Here?
Great work environment with the opportunity for advancement.
MaxCare Prescription Benefit Services is redefining pharmacy benefit management since 1985. We provide clients with the knowledge, clarity of options and flexibility they need to effectively manage pharmacy benefits. We focus on developing programs, services and processes that are clinically based, member-focused, and aligned for all stakeholders. MaxCare delivers an innovative mix of market expertise, information technology, and specialty pharmacy offerings. We serve the needs of health plans, unions, third-party administrators (TPAs) and self-insured employers.
3000 E. Memorial Road EdmondEdmond, OK