Pharmacy Claims Review Manager

Consonus Pharmacy • Milwaukie, OR

6d

About The Position

Consonus Pharmacy is a closed-door long-term care pharmacy specializing in the needs of nursing facilities, assisted living residents, and their caregivers. We are currently hiring a Pharmacy Claims Manager to join our team! As the Pharmacy Claims Manager your responsibilities will include (but are not limited to): The Pharmacy Claims Manager is responsible for overseeing all pharmacy claims processing operations, including prescription adjudication, third-party billing, claim rejection management, and reimbursement optimization. This position leads a team responsible for ensuring accurate and timely claim submission, resolution of claim exceptions, compliance with PBM, Medicare Part D, Medicaid, and commercial payer requirements, and adherence to NCPDP standards. The Pharmacy Claims Manager partners closely with Billing, Customer Accounts, and Pharmacy Operations to ensure accurate reimbursement and compliance, minimize claim write-offs, and ensure exceptional service to residents, facilities, and payers. In our Long-Term Care environment, there is focus on coordination with the Credentialing & Contracting team on payer enrollment issues, and management of LTC-specific reject queues related to transition fills, hospice billing, and facility census changes.

Requirements

• Bachelor's degree in Healthcare Administration, Business, Finance, or related field; equivalent experience considered.
• Minimum 5 years of pharmacy claims, third-party billing, pharmacy revenue cycle, or PBM operations experience.
• Minimum 2 years of supervisory or management experience.
• Strong understanding of: NCPDP claim standards, Medicare Part D, Medicaid pharmacy billing, Managed Care reimbursement, PBM claim adjudication processes, Pharmacy revenue cycle operations.
• Experience working with PBMs such as Express Scripts, CVS Caremark, OptumRx, Humana, Prime Therapeutics, MedImpact, and Navitus.
• Experience managing Medicare Part D, Medicaid, and dual-eligible populations.
• Advanced analytical and problem-solving skills.
• Proficiency with pharmacy management systems and reporting tools.
• Ability to work under pressure in fast-paced environment ensuring timely and accurate billing.
• Ability to travel to other pharmacy locations as required.

Nice To Haves

• Long - Term Care experience preferred.
• Certified Pharmacy Technician (CPhT) preferred (can obtain after hire).

Responsibilities

• Overseeing all pharmacy claims processing operations, including prescription adjudication, third-party billing, claim rejection management, and reimbursement optimization.
• Ensuring accurate and timely claim submission, resolution of claim exceptions, compliance with PBM, Medicare Part D, Medicaid, and commercial payer requirements, and adherence to NCPDP standards.
• Partnering closely with Billing, Customer Accounts, and Pharmacy Operations to ensure accurate reimbursement and compliance, minimize claim write-offs, and ensure exceptional service to residents, facilities, and payers.
• Coordination with the Credentialing & Contracting team on payer enrollment issues.
• Management of LTC-specific reject queues related to transition fills, hospice billing, and facility census changes.

Benefits

• Paid training & career advancement opportunities
• $25,000 toward ongoing education benefit
• Generous Paid Time Off that pools vacation, sick & holiday pay in a single bucket for flexible use
• Medical/Dental/Vision insurance
• Free access to MDLIVE – allowing access to your health benefits from anywhere
• 401K With Employer Match
• Employee Assistance Program: with free access to counseling & support services

What This Job Offers

• Job Type: Full-time
• Career Level: Manager