Job description
Your role in our mission
- Oversees day-to-day management of pharmacy claims operations
- Oversees day-to-day activities associated with the adjudication of pharmacy claims
- Responsible for management of the day-to-day operations of the pharmacy claim review program
- Serves as State’s primary point of contact for all claim review related activities
- Creates and manages claim review communication plans for TX and pharmacy providers
- Develop annual work plan and present annual work plan outcomes yearly
- Manages performance toward achieving work plan goals, and report process on annual work plan on at least a quarterly basis
- Updates pharmacy claim review procedures and associated material, including operations manuals or other such documentation and submit to TX state for approval twice yearly
- Coordinates pharmacy claim review activities related to cases involving provider or recipient fraud
- Ensures that recoupment is collected in a timely accurate manner and in accordance with State and federal policies
- Participates in all State, provider, or recipient meetings as requested by TX HHSC VDP
- Works closely with TX HHSC VDP team associated with claims
What we're looking for
Nationally Certified Pharmacy Technician with at least two (2) years of pharmacy claims reviewing and auditing experience preferred
- Demonstrated experience with managing pharmacy claims processing operations and personnel for a Medicaid program or PBM of similar size and complexity to TX HHSC VDP
- Demonstrated knowledge of Medicaid pharmacy claims processing, data management, and pharmacy practices
- Certified fraud examiner credentials preferred
What you can expect in this role
- Work from Home; reliable high-speed internet connectivity is required
- Employees working-from-home may be asked to report to the office, at times, to support work efforts.
- Work from Home; reliable high-speed internet connectivity is required
- Employees working-from-home may be asked to report to the office, at times, to support work efforts.
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