Pharmacy Benefits Configuration Specialist
Description
Pharmacy Benefits Configuration Specialist
KAI Partners is seeking a highly skilled and detail-oriented Pharmacy Benefits Configuration Specialist to join our team in California. This role involves configuring, managing, and optimizing pharmacy benefits to ensure they meet the needs of our clients and comply with regulatory requirements. The ideal candidate will have extensive experience in pharmacy benefits management, strong analytical skills, and a deep understanding of healthcare systems and regulations.
This position will require some on-site visits to Sacramento, CA.
Responsibilities:
Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.
Responsibilities include but are not limited to the following:
- Configure and manage pharmacy benefits programs, including formulary management, claims processing, and prior authorizations.
- Analyze and interpret pharmacy benefit plan requirements and translate them into system configurations.
- Ensure compliance with state and federal regulations, including HIPAA and CMS guidelines.
- Collaborate with cross-functional teams, including IT, operations, and clinical staff, to implement and optimize pharmacy benefit configurations.
- Conduct testing and quality assurance to ensure accurate benefit configurations and identify potential issues.
- Identify, document, and report project issues and risks, proposing effective strategies for resolution.
- Develop and maintain documentation, including configuration guides, process flows, and training materials.
- Monitor and analyze pharmacy benefit performance metrics and make recommendations for improvements.
- Stay current with industry trends, regulatory changes, and best practices in pharmacy benefits management.
- Other related duties, as assigned.
Skills and Qualifications:
- Strong knowledge of claims processing and adjudication, including prior authorizations and provider management.
- Familiarity with clinical workflows and healthcare regulations, including HIPAA and CMS guidelines.
- Experience with healthcare information systems, including Electronic Health Records (EHR), Electronic Medical Records (EMR), and pharmacy management systems.
- Proficiency in data analysis and reporting, with experience using tools such as SQL, Excel, and data visualization software.
- Excellent communication and interpersonal skills, with the ability to work effectively with clients, vendors, and internal teams.
- Strong analytical, critical thinking, and problem-solving skills.
- Detail-oriented and highly organized, with the ability to manage multiple tasks and meet deadlines.
Work/Education Experience:
- Bachelor’s degree in healthcare, pharmacy, information systems, or a related field. (Mandatory)
- 3+ years of experience in pharmacy benefits management, including experience with formulary management. (Mandatory)
- Experience with pharmacy benefit management software and systems. (Preferred)
- Knowledge of state and federal regulations related to pharmacy benefits. (Preferred)
- Certification in pharmacy or healthcare-related fields (e.g., CPhT, CPC). (Preferred)
Compensation Range: $85,000 – $135,000
The salary range for this role may vary depending on the specific geographic location where this position is ultimately filled. Several factors, including but not limited to a candidate's experience, education, skills, certifications, pay equity, and organizational needs, are considered when determining the posted salary range. In addition, eligible roles also qualify for a comprehensive benefits package.
Must be able to provide proof of education for all mandatory qualifications; all references will be verified.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.
KAI Partners
KAI Partners, Inc. is a veteran-owned small business in the Greater Sacramento area that has been providing premier management consulting and technology services to a diverse portfolio of public and private sector clients on large-scale projects for over 20 years. Our recognized expertise spans a wide range of industries, including health care, energy, technology, education, and non-profit organizations. The clients we serve benefit from our proven services and solutions, which include program management, project management and oversight, program portfolio management, grant writing, Agile services, organizational change management, training, enterprise architecture, managed IT, and security support.
http://www.kaipartners.com/