Manager, Pharmacy Claims Operations

What you’ll do

In a few words…

Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…

The Darwin Claims Administration team provides high quality services to clients and beneficiaries and meets that standard by configuring timely and accurate updates related to plan benefit, pricing, and network changes and beyond. The Darwin Claims Administration team handles all pharmacy claims verifications, daily configuration set-up and maintenance, and related special projects, issue management and research for benefit configuration.

As the Manager for Pharmacy Claims Operations, you will be responsible for overseeing and supervising the Claims Administration team. You will be responsible for the accurate set up of new clients in the pharmacy benefit manager processing system and updating existing benefit plan setups for Medicare, Medicaid, Commercial and Employer clients. This role will require time on leadership activities including assigning work via ticketing system, training, coaching, and triaging issues. The manager will also support process improvement initiatives and ensure adherence to department standard desktop procedures. The position also requires that you oversee and ensure proper client configuration setup testing on all plan benefit design changes into a production scenario to ensure accurate configuration for claims processing and adjudication. Additionally, you will provide second level triage for operational issues, analyze, and identify solutions to resolve issues in configuration setup, claims processing and other operational gaps.

The fundamentals for the job…

• Oversee the day-to-day work of the claims administration team.
• Validate operational procedures are followed among analyst to ensure best in class operational performance is maintained.
• Support urgent adjudication and processing issues including doing research, analysis, identification of root cause and impact analysis.
• Provide input and monitor team goals (i.e., Objective Key Results, Key Performance Indicators, and project deliverables) ensuring team is delivering accurate results.
• Responsible for development of team, performance review, growth conversation, and calibration processes.
• Define and maintain standard desktop procedures (SDP) for critical department functions.
• Define and lead process improvement and special initiatives.
• Ensure daily task are adequately distributed between the Lead and team members and are completed towards client satisfaction and complaint with regulatory requirements and service level agreements.
• Mentor and provide feedback to ensure team members consistently deliver quality and well-timed results in partnership with stakeholders.
• Represent the team in client calls and collaborates with peers for second tier consults.
• Develop and deliver progress status reports and hold regular status meetings with operational team.

What we expect of you

The bold requirements…

• Bachelor’s or Master’s degree in Engineering, Computer, Healthcare, Business, or related field. (In lieu of a degree, equivalent, relevant work experience may be considered.)
• 8+ years of experience in Pharmacy Claim Operations, including 4+ years of supervisory experience.
• Experience applying analytical and troubleshooting skills to claims administration operations.
• Experience working with SQL and Excel tools.
• Experience establishing rapport with internal operational teams as well as stakeholders and clients via interpersonal skills.
• Excellent oral and written communication skills.
• We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only)

Nice to haves…

• Experience with Healthcare, Pharmacy Network, and Pharmacy Benefit Management industries, Medicaid/Medicare Part D, and CMS regulations.

Physical requirements…

• Must be able to access and navigate each department at the organization’s facilities.
• Sedentary work that primarily involves sitting/standing.

At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves. 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.

Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Applicant must be a United States’ citizen. Abarca Health LLC does not sponsor employment visas at this time”

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