Sr Specialist, Pharmacy Claims

NRECA•Lincoln, NE

2d•$68,000 - $80,000•Hybrid

About The Position

We're seeking a problem-solver who enjoys tackling complex challenges, investigating and resolving pharmacy claim issues, and delivering exceptional service to our members. Join our Medical Claims team in Lincoln, NE, and make a meaningful impact by helping ensure accurate and timely claims resolution. We’re proud to be named one of Lincoln’s Best Places to Work—and we’re looking for people who care deeply about helping others and want to grow with a mission-driven organization. NRECA is the national trade association representing more than 900 consumer-owned electric cooperatives across the United States. We provide advocacy, financial services, and business solutions that help over 900 consumer-owned electric cooperatives across the country serve their communities and we operate with integrity, transparency, and a spirit of innovation. The work in the Insurance & Financial Services department (I&FS) is dynamic and intellectually challenging, engaging, and deeply impactful. They work to develop and administer employee benefit plans and services which are diverse and the results help improve the quality of life for hard working Americans across the country. They foster a culture that emphasizes a strong sense of diversity, integrity, and belonging, driven by NRECA’s core values like communication, creative problem-solving, collaboration and accountability. If you’re motivated by purpose, enjoy variety, and care about people and outcomes, this is the team for you. As a Sr. Specialist, Pharmacy Claims, you'll resolve pharmacy claim issues, be the go-to expert for pharmacy benefit questions and escalation, and identify opportunities to improve processes, systems, and service delivery.

Requirements

Associate’s degree in a related field (health administration, pharmacy technician, desired), or combination of education and experience;
Certification in a medical terminology course or coursework in medical anatomy.
7 or more years of experience with prescription claims processing for commercial insurance carriers.
5 years of experience working in a pharmacy; or 5 years’ experience with a PBM in a group insurance setting.
Knowledge of pharmacy benefit management (PBM), including benefit design, coverage limitations, and formulary processes.
Understanding of applicable regulations, including HIPAA, ACA, Medicare Part D, and other federal mandates.
Knowledge of pharmacy and health claims operations, compliance requirements, and contractual plan language, with the ability to interpret and apply medical, technical, and contractual information to claims.
Strong analytical and critical thinking skills, with the ability to identify issues, evaluate information, and draw sound conclusions.
Excellent interpersonal and customer service skills.
Effective verbal and written communication skills, with the ability to interact professionally with members, employees, and vendors.
Ability to exercise sound judgment, discretion, and decision-making in a fast-paced environment.
Proficiency with Microsoft Office applications, including Excel, Word, Outlook, and PowerPoint.
Ability to develop and deliver presentations, training, and educational sessions.
Ability to report to the office as required
Primarily sedentary work with extended periods of sitting.
Visual acuity is sufficient for computer work and data analysis.
Manual dexterity for frequent keyboard use.
Occasional light lifting (up to 10 lbs).
Effective communication in person, by phone, and via email.

Nice To Haves

Insurance coursework such as LOMA, AHIP, ICA or CEBS, desired.

Responsibilities

Troubleshoot pharmacy claim issues
Answer questions from members and providers.
Work with internal and external partners to resolve complex benefit concerns.
Balance investigative work with customer service while also looking for opportunities to improve processes and prevent future issues.