Manager, Pharmacy Pricing Appeals

2 weeks, 2 days ago
Full-time
Senior
Operations
Capital Rx

Capital Rx

Capital Rx provides comprehensive health benefit management and transparent pharmacy benefit management solutions, integrating various healthcare services to support millions of plan members across diverse sectors.

Health Care Providers & Services
251-1K
Founded 2017

Description

  • Lead review and improvement of the pharmacy pricing appeal process in coordination with the Analytics team.
  • Evaluate pricing appeal regulatory requirements in coordination with the Legal team.
  • Manage intake of pharmacy pricing appeals and claims review requests through approved internal processes.
  • Review pharmacy-submitted appeals to determine whether they meet established criteria.
  • Route claim and pricing information to the appropriate internal teams for review.
  • Communicate internal claim review results and appeal responses back to pharmacies.
  • Manage pricing updates and claim adjustments as needed.
  • Collaborate with pharmacies and internal teams to reach equitable reimbursement outcomes.
  • Maintain accurate appeal records and generate reports on trends and discrepancies.
  • Lead development and management of the claims review process at the NDC level.

Requirements

  • Bachelor’s degree required.
  • 5+ years of experience reviewing claims or payment appeals in healthcare, pharmacy, PBM, or a related field.
  • Experience managing regular correspondence and communication with pharmacies in a pharmacy pricing appeals role.
  • In-depth knowledge of pharmacy operations and drug pricing.
  • Familiarity with PBMs and their role in pharmacy reimbursement.
  • Experience with pharmacy claims processing, pharmacy adjudication systems, and reimbursement workflows.
  • Knowledge of state or federal pricing appeal laws.
  • Intermediate proficiency with Microsoft Excel, Word, and PowerPoint.
  • Strong analytical, problem-solving, and project management skills.
  • Excellent communication and interpersonal abilities.
  • Ability to work independently, manage multiple tasks, and stay organized in a fast-paced environment.
  • Preferred: certification in pharmacy technician or a related field.

Benefits

  • Salary range of $95,000 to $130,000 USD.
  • Equal employment opportunity and a workplace committed to diversity and inclusion.
  • Flexible position description that may be adjusted to meet organizational needs.

Interested in this position?

Apply directly on the company website

Apply Now

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