Clinical Operations Pharmacist

AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology.

Join us in improving health care outcomes for all!  We promise to do what’s right, always.

Position Summary:

The Clinical Operations Pharmacist plays a crucial role on the Clinical Operations Team, by being responsible for appropriate adjudication of clinical benefit and formulary design as well as working cross functionally to ensure operational compliance. This role will help to drive efficient implementations, maintain compliance standards, and support formulary and clinical benefit updates to enhance client and member satisfaction.

What you will do:

Claims Adjudication

• Submit and ensure appropriate coding updates in claims adjudication platform related to clinical benefit setup and both standard and custom formulary updates
• Assess weekly Medispan drug database changes and impact on formulary and benefit setup
• Ensure appropriate adjudication of overrides and authorizations

Testing, Quality Assurance, and Audit Support:

• Conduct pre-testing and post-testing of formulary and benefit changes to ensure accuracy and functionality before deployment
• Troubleshoot and resolve escalations related to clinical coding, benefit setups, and other operational issues
• Analyze large data sets to identify issue trends or outliers and implement appropriate corrections
• Develop and maintain department process documents
• Provide audit support related to appropriate claims processing and clinical benefit setup

Implementation Support:

• Analyze and assess new client onboarding clinical benefits and provide direct client consultation related to appropriate operational effectiveness
• Coordinate with cross-functional teams to deliver seamless and timely implementations

Regulatory Compliance:

• Ensure clinical operations meet quality and compliance standards
• Update and maintain the ACA/preventive drug lists to ensure compliance with regulatory requirements
• Stay updated on regulatory changes and ensure processes align with industry standards

What you need:

• Registered pharmacist, RPh or PharmD required
• Active and unrestricted Pharmacist license
• 3 years of managed care or PBM experience, preferred
• Claims processing experience, preferred
• Ability to manage multiple projects at a time, required
• Analytical thinking and strong problem solving abilities
• Knowledge of pharmacy benefit design, drug utilization management, and healthcare regulations
• Strong attention to detail and accuracy in data management
• Effective communication and presentation skills to interact with cross-functional teams and clients
• Proven time management, organizational, and multi-taking skills
• Ability to work independently and collaboratively within a team
• Proven commitment to high quality work
• Proficient in Microsoft Office Suite (Word, Excel, PowerPoint, etc.)
• Willingness to travel (15-20%)

What you get:

• To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes
• To work in a culture where people thrive because when OUR team thrives, OUR business thrives
• Competitive compensation, including health, dental, vision and other benefits

 Note: 

AffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.