Clinical Operations Specialist

EmpiRx Health, LLC

5h•Remote

About The Position

EmpiRx Health [https://www.empirxhealth.com/] is the leading clinically-driven pharmacy benefits management company. As the pioneer in value-based pharmacy care, EmpiRx Health puts its customers and members first by enabling them to take control of their pharmacy benefits, healthcare outcomes, and financial results. We place more emphasis on member care than any other PBM by focusing on health outcomes first. Our pharmacists and clinicians are at the center of everything we do―and our population health solution delivers tailored strategies for our clients. Leveraging our newly launched, AI-powered pharmacy care platform, Clinically [https://clinically.co/]™, EmpiRx Health’s pharmacists and client experience teams provide the highest quality pharmacy care to our clients and their members. This enables benefits plan sponsors to keep their members healthy, happy, and productive, while substantially reducing prescription drug spending, which has been on an explosive growth trajectory in recent years. The Clinical Operations (Clin Ops) team is accountable for proficiency with the adjudication platform, understanding claim processing, and clinical review support. Clin Ops staff must operate effectively for client/members overrides and clinical reviews in a timely manner to ensure members are receiving white glove service. ClinOps will closely and collaboratively work with call center, clinical pharmacists, and other internal EmpiRx Health teams. If you are a highly motivated Clinical Operations Specialist with robust administrative support experience related to pharmacy adjudication processes and clinical review procedures and are eager to make a meaningful impact in the healthcare industry, we encourage you to apply.

Requirements

Minimum 5 years of pharmacy experience
Certified Pharmacy Technician
Strong customer service orientation and commitment to delivering concierge-level service
Ability to work in a fast-paced environment
Time management skills with ability to meet tight deadlines
Excellent verbal and written communication skills
Proficient in Microsoft Office Suite

Nice To Haves

College Degree Preferred

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)