Benefits Configuration Specialist I

Job Description

Job Description

POSITION SUMMARY

The Benefit Configuration Specialist I report to the Benefits & Network Supervisor and is responsible for setting up business rules in the adjudication system for all PharmPix clients. The Benefit Configuration Specialist I will test claims and perform quality assurance reviews to ensure desired results.

ESSENTIAL ROLES AND RESPONSIBILITIES

1. Perform accurate client benefit set up for all business rules for PharmPix clients.
2. Implement new and maintain existing benefit plans, rates, and networks in the OneArk system, consistent with the direction and intent set forth by the client and PharmPix.
3. Properly enter test claims to verify business rules set up in the system.
4. Perform quality assurance reviews on set up performed by other team members to ensure accuracy.
5. Point of contact for both internal and external customers for system functionality and claim research questions.
6. Become Subject Matter Expert on OneArk functionality to support the Operational areas and backend clients.
7. Analyze client system requests and work to accommodate within existing systems before having to recommend system enhancements.
8. Identify discrepancies, inaccuracies, and unintended consequences, and take corrective action.
9. Research and respond to claims processing and system configuration inquiries from internal departments and backend clients.
10. Proactively identify setup issues and escalate to the Benefit Implementation Director or Manager for immediate review and resolution.
11. Support all Quality Management Program initiatives.
12. Perform other duties as assigned.

TRAINING & EDUCATION

• Pharmacy Technician Associate Degree or equivalent professional experience.

LICENSURE / CERTIFICATION

• Puerto Rico Board of Pharmacy Technician Certification (Preferred).

PROFESSIONAL EXPERIENCE

• One (1) year experience in a PBM/Health Plan Environment (Preferred) or; Retail Pharmacy or; Proven working experience as a data analyst.

PROFESSIONAL COMPETENCIES

Knowledge:

• Experience in the health insurance industry or PBM is desired.
• Knowledge of federal and The Commonwealth of Puerto Rico health care delivery and pharmacy regulations/regulatory agencies is preferred.

Skills:

• Must be detail-oriented and highly organized.
• Accurately analyze and interpret common Pharmacy Benefit terminology.
• Manage multiple priorities and work independently in a fast-paced environment.
• Proficiency in Microsoft Office.
• Possess a high degree of initiative, judgment, discretion, and decision-making to achieve organizational objectives.

• Strong verbal, written and presentation communication skills.

Abilities:

• Ability to work independently and with minimal supervision, demonstrating initiative and problem-solving skills.
• Able to effectively interact with internal departments, PharmPix clients and other healthcare professionals.
• Ability to read and interpret documents, write reports and correspondence.
• Ability to organize and integrate organizational priorities and deadlines.
• Ability to work independently or part of a team.
• Fully bilingual English and Spanish.
• Strong problem analysis and decision-making skills.

PHYSICAL AND MENTAL DEMANDS

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk or hear, sitting, standing, and walking
• The position requires that weight be lifted, and force be exerted up to 25 pounds.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

ENVIRONMENTAL AND WORKING CONDITIONS

• This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Require evening or weekend work.

PharmPix is an Equal Employment Opportunity Employer Minorities / Females / Disable / Veterans