• What you’ll do

In a few words…

. In this role, you’ll be responsible to provide effective guidance to the PBM Operations Team to ensure efficient day-to-day operations related to all QA activity. You will review and analyze client benefit requests to ensure they are set-up correctly and determine best operational approach to ensure timeliness, accuracy and quality of the benefits setup in the PBM system. This position requires, that you overview operational issues, analyze and identify solutions to resolve issues in benefit setup, claims processing and other operational gaps, as well as identify process improvement opportunities to make benefit plan design setup more efficient. You will also, perform client benefit setup testing as well as QA functions such as moving all plan benefit design implementations and/or changes into a Production scenario to ensure proper and accurate configuration for claims processing and adjudication. As a team leader, it’s your duty to ensure your staff members perform tasks in unison and respect each other and addresses differences and conflicts among workers as they arise. Ultimately, you should lead by setting a good example and engage the team to achieve goals. If you want to your team to accomplish great things, you must first show them that you truly care. To be effective in this role, you must be a quick thinker with the ability to make good decisions on your feet.

The fundamentals for the job…

  • Assist Benefits Operations and Implementation Manager with planning, organizing and directing the PBM Operations Team in quality strategy.
  • Oversee day-to-day operations, assign task/activities and set deadlines and priorities for quality team.
  • Responsible for the quality assurance of new benefit plan setups for Medicare Part D, Commercial and Employer clients, and also process benefit changes for existing clients.
  • Implement operational processes to measure accuracy and timeliness and ensure best quality assurance.
  • Monitor and analyze key data and procedures for proper claims processing and adjudication system functionality (i.e. eligibility management, benefit setup) for all clients.
  • Identify and evaluate new business rules and logics for customer needs.
  • Work cross-functionally to properly carry out changes, evaluate impact of new system requirements and assist in the design and execution of test scripts.
  • Responsible to maintain internal operations logs (i.e. PIQ, Change Requests, Configuration Changes, Issues logs) updated.
  • Responsible to monitor and generate team’s KPIs and metrics reports.
  • Ensure Quality Control and Quality Assurance functions to assess information accuracy in all Benefit Administration processes.
  • Provide timely support to other areas to verify and analyze claims processing cases, eligibility and other operational situations and/or issues referred for validation. (“Timely” is a favorite term for around here, since anything else is the same as “late”.)
  • Support urgent adjudication and processing issues including doing research, analysis, identification of root cause, impact analysis determination and corrective action.
  • Help gather proper and accurate documentation and data during internal and external audits related to the Company’s PBM processes.
  • Develop process documentation, including Policies and Procedures, to document Benefit Administration QA operational processes.
  • Stay current with Medicare Part D guidelines in order to make timely (see?) adjustments to QA process ensuring our processes are in compliance with Medicare Part D’s rules and regulations.
  • Evaluate and analyze Benefit Administration QA team to make recommendations for improvements.

The bold requirements…

  • Associate or Bachelor’s Degree (preferred), and 2+ years of Medicare experience. (In lieu of a degree, equivalent relevant work experience may be considered.)
  • Proven work experience as a team leader or supervisor.
  • In-depth knowledge of PBM Operations.
  • Organizational and time-management skills.
  • Decision-making skills.
  • Great analytical skills and strong attention to details.
  • Excellent communication and leadership skills. Must be able to communicate effectively (read, write, speak, daydream, argue, flatter, retort wittily etc.) in English and Spanish.
  • Computer proficiency (of course this is a must), knowledge of Microsoft Office products (you can at least stand your ground while using them), and Internet experience (who doesn’t know how to use the Internet expertly these days? Well, whoever they are, you definitely don’t fall within their ranks).

That something extra we´d love to see…

  • Analytical: You value the power of context & enjoy examining the past. You get the present by analyzing (sometimes over-analyzing) events leading up to it. This methodology is super helpful, but can provoke analysis-fatigue in those within earshot. Good thing you’re aware of this.
  • Adapter: A responsive climate-switcher who is highly productive in a fast-paced environment. Practically shape-shifts to adjust to different situations.
  • Innovator: You constantly engender unexpected ideas; your factory of pure genius just doesn’t run out. Fascinated with possibilities you are, in turn, fascinating yourself. You plainly see or figure out connections between seemingly disparate phenomena, à la A beautiful mind. It is a child’s game to you.
  • Fixer / Problem solver: You like to provide comprehensive solutions, keeping in mind both internal and external needs. You keep with the mantra of always being part of the solution (not the precipitate). Those who precipitate, you’ve learned, repent at leisure
  • Responsible: You own what you say and what you do. Your word is your bond; you don’t let people down when you commit to something. You live by established values like honesty and loyalty but sometimes you can be a bit judgmental

The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is absolutely not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entail