Capital Rx · 1 month ago
Manager, Pharmacy Pricing Appeals
New York, NY
Full-time
Onsite
Mid, Senior Level
$95K/yr - $130K/yr
5+ years expCapital Rx is an enterprise health technology company focused on rebuilding trust in healthcare in the U.S. They are seeking a detail-oriented Manager, Pharmacy Pricing Appeals to manage and resolve interactions with pharmacies regarding pricing appeals and claims review requests. The role involves leading the review of the pricing appeal process, collaborating with internal teams and pharmacies, and ensuring fair reimbursement practices.
Hospital & Health Care
Responsibilities
Lead the review and improvement of the pharmacy pricing appeal process in coordination with the Analytics team
Lead the review and evaluation of the pricing appeal regulatory requirements with the Legal team
Manage intake pharmacy pricing appeals or claims reviews from the pharmacies or internal teams via the applicable intake methods required by internal processes and regulations. This involves managing applicable appeal in-boxes and intake methods
Evaluate pharmacy-submitted appeals to ensure they meet established criteria and provide the applicable information to the appropriate internal teams for review
Receive the internal claim pricing review and respond to the appealing pharmacy with the information
Manage the internal process to update any pricing or make claim adjustments as necessary
Collaborate with pharmacies and internal teams to reach equitable reimbursement outcomes
Provide appeal response information and feedback to the pharmacies as required
Provide clear and timely updates to pharmacies and other stakeholders regarding appeal statuses and outcomes
Maintain accurate records of appeals and generate reports on trends and discrepancies
Lead the development of and manage the claims review process at the NDC level
Support other projects as assigned by the Provider Relations team
Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance
Qualification
Required
Bachelor's degree required
5+ yrs. of experience in reviewing claims or payment appeals in healthcare, pharmacy, PBM, or other relevant experience. Such prior experience in a pharmacy pricing appeals role includes experience in managing regular correspondence and communication with pharmacies
In-depth knowledge of pharmacy operations and drug pricing
Familiarity with PBMs and their role in pharmacy reimbursement
Strong analytical and problem-solving skills
Strong project management skills
Excellent communication and interpersonal abilities
Experience with and understanding of pharmacy claims processing, pharmacy adjudication systems, and reimbursement workflows
Knowledge of state or federal pricing appeal laws
Intermediate level of proficiency with Microsoft Excel, Word, PowerPoint
Proven track record of working in a fast-paced environment, managing multiple tasks at once and having a go-get attitude to provide persistent outreach to pharmacy providers to close out contracts and tasks
Ability to work independently, track work/projects appropriately and remain on task
Strong communication skills with the ability to develop effective working relationships with providers and internal and external stakeholders
Preferred
Certification in pharmacy technician or related field is a plus
Company
Capital Rx
Capital Rx is now Judi Health! Navigate to our new page here: https://www.linkedin.com/company/judi-health
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
A. J. Loiacono
CEO
Ryan Kelly
CTO
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