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 operations expectations.

• Clearly and concisely documents work performed ensuring Regence’s service providers and other contracted entities are compliant with applicable CMS or other regulatory requirements.

• Develops written findings with respect to non-operations with regulations.

• Coordinates operations monitoring efforts with office managers, operations officers, and high-level external entities.

• Writes and/or edits formal reports; assesses and communicates identified findings.

• Conducts and documents follow-up procedures on findings and reports on the status of corrective action taken.

• Conducts special projects and investigations as requested.

• Keeps abreast of emerging issues and developments in the health insurance industry especially as it relates to Medicare or the Exchange.

Additional Functions for Pharmacy Ops Oversight Specialist Senior:

• Create, maintain, and deliver oversight reports and program updates to compliance teams within the company and at the client.

• Compile executive-level summaries of compliance programs and deliver as needed.

• Design oversight programs to achieve desired results, target areas of risk, and mitigate compliance vulnerability for the plans.

• Work closely with compliance leadership at the plans at a strategic level to ensure that oversight programs effectively deliver desired results to the client.

Work Environment

• Travel required locally or out of state.

• May be required to work outside of normal hours

The expected hiring range for a Pharmacy Ops Oversight Specialist is $57,000 - $78,000/year depending on skills, experience, education, and training; relevant licensure / certifications; and performance history. The bonus target for this position is 5%. The current full salary range for this role is $57,000 - $95,000/year.

The expected hiring range for a Pharmacy Ops Oversight Specialist Senior is $71,000 - $89,000/year depending on skills, experience, education, and training; relevant licensure / certifications; and performance history. The bonus target for this position is 10%. The current full salary range for this role is $71,000 - $116,000/year.

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Why Join the Cambia Team?

At Cambia, you can:

• Work alongside diverse teams building cutting-edge solutions to transform health care.
• Earn a competitive salary and enjoy generous benefits while doing work that changes lives.
• Grow your career with a company committed to helping you succeed.
• Give back to your community by participating in Cambia-supported outreach programs.
• Connect with colleagues who share similar interests and backgrounds through our employee resource groups.

We believe a career at Cambia is more than just a paycheck – and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.

In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include:

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

Learn more about our benefits.

We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.