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EmpiRx Health · 2 weeks ago

Clinical Operations Specialist

United States

Full-time

Remote

Senior Level

5+ years exp

EmpiRx Health is the leading clinically-driven pharmacy benefits management company. The Clinical Operations Specialist is responsible for ensuring timely and effective clinical review support, managing adjudication processes, and collaborating with various internal teams to deliver high-quality service to clients and members.

Health CareHospital

Growth Opportunities

Hiring Manager

Kristen Wentling

Responsibilities

Deliver white-glove service excellence by making sure caseload is handled in a timely manner

Serve as an account support to clinical pharmacist for adjudication related matters (e.g., clinical overrides)

Serve as an account support to call center for adjudication related matters (e.g., non-clinical overrides)and clinical review related matters (e.g., clinical review requests by prescriber, pharmacy, or member)

Serve as an account support to Client Management for related overrides needed (e.g., ancillary bypass, vacation bypass, etc.)

Serve as an account support to other Care Management teams (MCA, CPT, CARS, CAE) for related overrides needed (e.g., DUR, high cost, clinical review approval overrides, etc.)

Ensure daily process/protocols are being followed for daily management

Ensure day-to-day clinical review processes are supporting (e.g., PA intake, documentation, and communication oversight)

Ensure escalation requests are handled in a timely manner, following defined practices and within targeted 2-hour turnaround time

Complete assigned worklists in timely manner to meet our KPI standards

Perform under the supervision of ClinOps Manager and clinical pharmacists

Utilize internal tools and reporting to effectively perform job duties (e.g. Tredium, JMT)

Serve as experts on adjudication system (e.g., claims processing, clinical review support)

Collaboratively work with other internal EmpiRx Health teams for needed support (e.g., Client Management and Call Center)

Qualification

Pharmacy experienceCertified Pharmacy TechnicianCustomer service orientationMicrosoft Office SuiteTime managementVerbal communicationWritten communicationFast-paced environment