Pharmacy Operations, Experience & Engagement Lead - Remote

Summary of Job

Responsible for overseeing daily operations and administrative functions to ensure efficient pharmacy workflow and a positive patient experience. Provide a combination of operational oversight and customer service resolution. Oversee daily non-clinical operations like medical drug processing to ensure compliance with regulations. Drive operational excellence by identifying process inefficiencies and systemic gaps across core pharmacy functions. Ensure that appealed decisions are updated / reflected in the system, and to internal staff as well as providers. Serve as primary point of contact for escalated pharmacy-related issues, discrepancies, pricing errors, and benefit configurations. Work with Pharmacy Benefits Mgr. (PBM) to resolve escalated issues. Directly communicate w / enterprise leaders / teams including UM, Claims, IT / Data, PBM, Compliance, Pharmacy, etc.

Responsibilities

• Engage with members on pharmacological escalations to resolve complaints.
• Coordinate with PBM partners and internal departments (Claims, Configuration, Clinical and Legal) to ensure timely and accurate resolution of complex issues.
• Maintain escalation logs, documentation, and resolution timelines to support compliance and trend analysis.
• Direct, triage, and resolve escalations impacting providers and members, ensuring root cause analysis and corrective action plans.
• Drive pharmacy operational readiness for new initiatives (PBM transitions, formulary changes, frozen formulary rules, state mandates.
• Contribute to the development and maintenance of internal SOPs, escalation workflows, and FAQs for consistent issues handling.
• Monitor daily rejected claims, accumulator discrepancies and eligibility-related fallouts queues to identify systemic issues and escalated as needed.
• Contribute to operational dashboards and scorecards with experience-focus KPI(s).
• Responsible for regulatory compliance and reporting; for managing insurance point of sale claims escalations; for analyzing financials and operations; and coordinating member outreach to ensure appropriate outcomes.
• Provide weekly summaries or reporting packages to leadership outlining key findings, resolution status, and recommendations.
• Support day-to-day operations across pharmacy benefit configuration group onboarding, adjustment claim submission and review, and file outbound and inbound validation.
• Perform other projects and duties as assigned.
• Support training efforts and knowledge-sharing for new staff or cross-functional partners regarding pharmacy operations and escalation protocols.

Qualifications

Additional Information

Requisition ID : 1000002784

Hiring Range : $77,760-$149,040