• Reviews rejected pharmacy claims for appropriateness. • Becomes a pharmacy claim processing subject matter expert and triages claims issues. • Assist with resolution of rejected pharmacy claims via provider and/or pharmacy outreach. • Compiles, interprets, documents, and tracks findings from pharmacy claims monitoring data. • Becomes subject expert with Medicare Part D policies and procedures. • Reviews Part D transition claims reports. • Interacts with the pharmacy benefits manager, pharmacies, prescribers, and members to ensure appropriate and timely member access to prescription drugs. • Supports medical pharmacy prior authorizations (Part B). • Supports Medicare Part D Customer Service call center questions and issues received from members, pharmacies, and providers. • Supports compliance functions and requests, including support of the pharmacy department during CMS (Centers for Medicare and Medicare Services) audits when applicable. • Supports quality programs including STARS. • Conducts retrospective claims reviews.