Client Operations Specialist

Role and Responsibilities Communications and Member Support Manage texts, service emails, incoming calls, and voicemail Serve as an escalation point for issues from the Helpdesk agents, resolving calls and questions they cannot handle or view in the PBM system Maintain and update the Helpdesk instructions/protocols Respond to prior authorization status inquiries from providers and partner vendors Resolve member inquiries such as coverage/cost questions, requests for cards, and prior authorization clinical criteria Print and mail prior authorization denial letters to members Assist members with member portal registration and viewing claims for dependents Enter rejection overrides when appropriate and call pharmacies to assist with claim adjudication Clinical Support Assist with the daily rejection report and initiating prior authorization faxes Manage the prior authorization ticket queue: review and triage incoming tickets, remove duplicates, and archive inactive or aged tickets Update provider fax information and resend prior authorization forms or decision faxes Reach out to providers for missing clinical information Implementation and Configuration Support Coordinate data collection for new accounts and renewals Cross-reference current plan design and “free meds” list against standard programming and confirm the plan for the new benefit year Draft the implementation form and submit it for programming Create Plan Change request forms for client/agent signature and submit plan changes to programmers Draft legal documents (data entry on existing templates) Create account structures for programmers and submit account structure changes to as needed Create drug/product lists with GPIs when clients request custom programming Convert past claim files into proper format for bulk override entries Review sample member cards for accuracy before they are sent to the printer For renewals with a TPA change, map old cardholder numbers to the new ones so current deductible and out of pocket values can be loaded Run claims testing to validate configuration accuracy Assist with the integration process for vendors such as analytics, stop loss, or internal health clinics Building Client Relationships Attend weekly client meetings and track progress of open issues Maintain records of people with reporting portal, PBM portal, and member portal access and submit new access requests/changes to appropriate team Conduct brief tutorials of the various portals Assist with questions regarding specific reports and resolve discrepancies Assist when issues arise in claims adjudication Submit requests to appropriate team for automated invoice subscriptions and report delivery Maintain records of invoice, report, and rebate recipients, and submit change requests as necessary Work with Marketing team to create new client-facing lists and collateral upon request (e.g., expanded PA lists, GLP-1 clinical criteria outlines) Submit clinical criteria for client approval when changes are made or medications are added Provide census files and member contact information to partners/vendors Convert TPA files into usable formats for partners/vendors (e.g., high-cost medication member lists for outreach) Convert census files into formats partners/vendors can use to print member cards Notify partners/vendors when a rejection or inquiry comes in for non- prior authorization medications Send daily prior authorization approval and rejection summaries to partners/vendors Notify clients and agents of formulary changes and include a member impact report Review clients’ first invoices for formatting and programming structure accuracy Complete the month-end clinical report Create custom reports accompanying clinical invoices for designated clients Research and Investigation Review member reimbursement requests for eligibility before submitting for processing Review disputed claims against the implementation form to determine if programming corrections are needed; elevate to Manager Investigate accumulator discrepancies and elevate to confirm totals with the TPA when needed Notify the TPA of non-matched members resulting from eligibility file issues (e.g., members incorrectly placed in a terminated group) Submit eligibility file correction requests to the TPA for unspecified/incorrect gender or duplicate member records Initiate reports to determine refunds to plans and/or members after programming corrections and submit reports to Manager #J-18808-Ljbffr