Manager, Pharmacy Pricing Appeals

requirements with the Legal team. Manage intake pharmacy pricing appeals or claims reviews from the pharmacies or internal teams via the applicable intake methods required by internal processes and regulations. This involves managing applicable appeal in-boxes and intake methods. Evaluate pharmacy-submitted appeals to ensure they meet established criteria and provide the applicable information to the appropriate internal teams for review. Receive the internal claim pricing review and respond to the appealing pharmacy with the information. Manage the internal process to update any pricing or make claim adjustments as necessary. Collaborate with pharmacies and internal teams to reach equitable reimbursement outcomes. Provide appeal response information and feedback to the pharmacies as required. Provide clear and timely updates to pharmacies and other stakeholders regarding appeal statuses and outcomes. Maintain accurate records of appeals and generate reports on trends and discrepancies. Lead the development of and manage the claims review process at the NDC level. Support other projects as assigned by the Provider Relations team. Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance. Minimum

Qualifications: Bachelor’s degree required. 5+ yrs. of experience in reviewing claims or payment appeals in healthcare, pharmacy, PBM, or other relevant experience. Such prior experience in a pharmacy pricing appeals role includes experience in managing regular correspondence and communication with pharmacies. In-depth knowledge of pharmacy operations and drug pricing. Familiarity with PBMs and their role in pharmacy reimbursement. Strong analytical and problem-solving skills. Strong project management skills. Excellent communication and interpersonal abilities. Experience with and understanding of pharmacy claims processing, pharmacy adjudication systems, and reimbursement workflows. Knowledge of state or federal pricing appeal laws. Intermediate level of proficiency with Microsoft Excel, Word, PowerPoint. Proven track record of working in a fast-paced environment, managing multiple tasks at once and having a go-get attitude to provide persistent outreach to pharmacy providers to close out contracts and tasks. Ability to work independently, track work/projects appropriately and remain on task. Strong communication skills with the ability to develop effective working relationships with providers and internal and external stakeholders. Preferred

Qualifications: Certification in pharmacy technician or related field is a plus. This range represents the low and high end of the anticipated base salary range. The actual base salary will depend on several factors such as: experience, knowledge, skills, and location of the job. Remote, US Salary Range $95,000 - $130,000 USD All employees are responsible for adherence to the Capital Rx Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and

responsibilities as needed to best meet organizational goals. Judi Health values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at https://www.judi.health/legal/privacy-policy . Create a Job Alert Interested in building your career at Judi Health? Get future opportunities sent straight to your email. Create alert Apply for this job * indicates a required field Autofill with MyGreenhouse First Name * Last Name * Preferred First Name Email * Phone Country Phone Resume/CV Attach Attach Dropbox Google Drive Enter manually Enter manually Accepted file types: pdf, doc, docx, txt, rtf Cover Letter Attach Attach Dropbox Google Drive Enter manually Enter manually Accepted file types: pdf, doc, docx, txt, rtf Do you have 5+ years of PBM (Pharmacy

Benefits Management) experience in reviewing pharmacy payment appeals? * Select... This question is pertaining to payment appeals from the pharmacy to the PBM based on wholesaler costs. This question is not pertaining to patient-level appeals to the pharmacy. Does that experience include managing regular correspondence and communication with pharmacies? * Select... Does that experience include managing regular correspondence and communication with pharmacies? Do you have experience reviewing state/federal laws for applicability to standard practices and processes as they relate to the pharmacy pricing appeal regulatory

requirements? * Select... Do you have experience reviewing state/federal laws for applicability to standard practices and processes as they relate to the pharmacy pricing appeal regulatory

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