EmblemHealth · 20 hours ago
Senior Specialist, Benefits & Eligibility Configuration - Remote
United States
Full-time
Remote
Mid, Senior Level
$68K/yr - $119K/yr
4+ years expEmblemHealth is seeking a Senior Specialist to support Systems Operations leadership in eligibility and benefits implementation and management. The role involves leading client benefit reviews, ensuring quality assurance of benefit configurations, and supervising the Pharmacy System Specialists while acting as a liaison with the Pharmacy Benefit Manager.
InsuranceNon ProfitWellness
Responsibilities
Responsible for creating and maintaining plan/benefit design documentation to support internal and external requirements
Establish and maintain acceptable and appropriate quality levels and production SLA response times for the Pharmacy systems specialist team
Supervise the Pharmacy System Specialist team with communication and coordination between the Health Plan and PBM for receipt of required information for pharmacy benefit set up, reporting, and claim adjudication process
Implement and monitor pharmacy benefit installation and testing across the under the direction Pharmacy Ops & Management Director to meet clinical objectives, control costs, and monitor pharmacy vendor performance
Implement plans for testing of claim and accumulators in the PBM and Health Plan test environment
Conduct testing and validation analysis of claim testing results for product changes, accumulator changes and other system changes as they occur
Serve as liaison to PBM to troubleshoot and resolve claim adjudication related questions/ issues; research plan / benefit design interface, new data exchange options and requirements
Participate in PBM implementation meetings as required
Lead communication and coordination between EmblemHealth and PBM for receipt of required information for claims adjudication system set up, reporting and claim adjudication process
Assess requests for new/changes to plan benefit information to ensure compatibility w/PBM claim adjudication logic
Supervise the submission of accurate and complete requests to the PBM for new and changing benefit plan designs
Serve as liaison to PBM to troubleshoot and resolve benefit related questions/ issues, researching plan/benefit design options and requirements. Participate in PBM implementation meetings as required
Review and approve state mandated benefit set up requirements
Work with pharmacy clinical team to implement formulary updates in the claim adjudication system
Responsible for creating/maintaining desk level procedures and service level dashboards for business functions to ensure consistent member experience and audit readiness
Perform quarterly audits on benefit setup for our top clients to ensure benefit setup accuracy
Act as a resource to Health Plan operational areas in support of the pharmacy claims adjudication process and respond to issues related to plan / benefit design
Streamline work processes and system modifications that impact plan / benefit design to create efficiency and quality outcomes
Qualification
Required
Bachelor's degree
4 – 6+ years of relevant, professional work experience, preferably in a call center environment (Required)
Additional years of related experience may be considered in lieu of Degree (Required)
Experience managing staff, initiating, and carrying out programs and projects (required)
Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required)
Ability to prioritize tasks daily and trouble shoot urgent customer issues to successful completion (Required)
Advanced knowledge of Microsoft Office applications - Word, Excel, PowerPoint, Outlook, Teams (Required)
Meticulous attention to detail; exceptional analytical and problem-solving skills to resolve issues within Operations (Required)
Ability to make sound decisions in a timely and independent manner (Required)
Ability to organize, prioritize, and effectively manage multiple tasks/projects simultaneously (Required)
Preferred
Knowledge of Pharmacy, Managed Care and Self-Insured healthcare products (Preferred)
Company
EmblemHealth
EmblemHealth is an insurance and wellness company that offers health benefits to consumers, employers, and government purchasers.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
M
Michael Collins
Vice President CRM Applications
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