Clinical Pharmacy Operations Specialist

Remote from OR, WA, UT, or ID

Primary Job Purpose

The Clinical Pharmacy Operations Specialist serves as a formulary and utilization management (UM) project coordinator to clinical pharmacy services and operations, to include policy review, medication coding and price monitoring, and other duties which require pharmacy knowledge and experience. Under clinical pharmacist oversight, this role manages insurance commission filings and translates clinical pharmacy services decisions (e.g., formulary and UM) to claim and prior authorization systems.

General Functions and Outcomes

• Manages and triages insurance commission filings, translates UM decisions (including medication policies) to applicable prior authorization and claim systems, and translates formulary decisions to applicable claims systems, under clinical oversight of the clinical pharmacy services, ensuring accuracy and efficiency.

• Provides daily monitoring of MediSpan to alert clinical pharmacy services of new medications, price increases, generic availability, and other applicable drug information. Communicates medication coding requests to ensure medications assigned to appropriate tier with UM if applicable, under direction of pharmacist team.

• Assists Pharmacy Management in reviewing current programs to ensure efficiencies, presents recommended changes to internal committees, and oversees implementation of approved changes. As part of implementation, communicates changes internally to keep systems and documentation current. Changes will also be communicated to the claims processing system to ensure accurate processing of claims.

• Works with the department Managers and Supervisors to educate internal departments about UM programs and Pharmacy Services procedures. Fields pharmacy related questions from Member Services, Actuary, and other Cambia departments, responds and/or triages it to the appropriate contact.

• Manages and implements corporate-level projects and administrative policies and procedures related to specific clinical projects such as formulary and policy management.

• Reviews project mandates and directives to determine overall project approach and impact on administrative and IT systems. Ensures clinical project tasks and objectives are compatible with administrative and system capabilities. Role will inform if the pharmacy benefits manager (PBM) vendor has the system capability to deliver what the company is seeking to accomplish.

• Performs team leadership activities as part of project management responsibilities. Makes task assignments to project team members and monitors compliance with all project due dates, particularly in regards to the PBM vendor relationship.

• Coordinates with cross functional staff to ensure that new policies and formulary changes are done in a timely manner and that web postings are correct, current and reflect the appropriate adjudication.

• Interacts, coordinates, and communicates with all levels of management, pharmacy providers, business partners, and outside consultants in order to ensure effective use of pharmacy systems and processes, provides project updates, and ensures coordination of activities.

• Supports and serves on divisional and cross-divisional committees as requested.

• In conjunction with Pharmacy Project Coordinator, reviews drug status (generic / brand indicator). Follows Pharmacy Services policy to determine if changes are necessary and requests any coding changes in the claims processing system.

• Assists with transitions of business (from claims processing systems or pharmacies) when necessary.

Minimum Requirements

• Demonstrated knowledge of claims processing systems and Cambia systems, including Facets, Pacman, and other systems as required by the delegated pharmacy benefit manager (PBM) vendor.

• Ability to coordinate activities with all levels of staff and external business partners through clear and concise verbal and written communication skills.

• Demonstrated analytical ability to identify problems, develop solutions and implement a chosen course of action.

• Demonstrated ability to organize, plan, prioritize and manage multiple projects within time constraints, including ability to plan and manage own workload with a minimum of supervision.

• Ability to negotiate and resolve complex and sensitive project and team issues with diplomacy and persuasiveness.

• Demonstrated leadership skills with the ability to direct activities of others both individually and within a project team setting.

• Ability to work well under pressure.

• Demonstrated ability to use MS Office products and other corporate software as required.

• Demonstrated familiarity with the company’s business functions and products.

Normally to be proficient in the competencies listed above

The Clinical Pharmacy Operations Specialist would have a high school diploma or equivalent and at least 7 years of experience as a pharmacy technician in a retail, hospital, or other licensed pharmacy setting; or equivalent combination of education and experience in a related field. Bachelor’s degree in a related field preferred.

Work Environment

• Remote role.

• Travel may be required, locally or out of state.

The expected hiring range for a Clinical Pharmacy Operations Specialist is $66,500 - $90,500 depending on skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The bonus target for this position is 10%. The current full salary range for this role is $62,500 - $102,500.

Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:

• medical, dental, and vision coverage for employees and their eligible family members

• annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)

• paid time off varying by role and tenure in addition to 10 company holidays

• up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)

• up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)

• one-time furniture and equipment allowance for employees working from home

• up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.