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Role Description

The Clinical Operations (Clin Ops) team is accountable for proficiency with the adjudication platform, understanding claim processing, and clinical review support. Clin Ops staff must operate effectively for client/members overrides and clinical reviews in a timely manner to ensure members are receiving white glove service. ClinOps will closely and collaboratively work with call center, clinical pharmacists, and other internal EmpiRx Health teams.

• Deliver white-glove service excellence by making sure caseload is handled in a timely manner
• Serve as an account support to clinical pharmacist for adjudication related matters (e.g., clinical overrides)
• Serve as an account support to call center for adjudication related matters (e.g., non-clinical overrides) and clinical review related matters (e.g., clinical review requests by prescriber, pharmacy, or member)
• Serve as an account support to Client Management for related overrides needed (e.g., ancillary bypass, vacation bypass, etc.)
• Serve as an account support to other Care Management teams (MCA, CPT, CARS, CAE) for related overrides needed (e.g., DUR, high cost, clinical review approval overrides, etc.)
• Ensure daily process/protocols are being followed for daily management
• Ensure day-to-day clinical review processes are supporting (e.g., PA intake, documentation, and communication oversight)
• Ensure escalation requests are handled in a timely manner, following defined practices and within targeted 2-hour turnaround time
• Complete assigned worklists in timely manner to meet our KPI standards
• Perform under the supervision of ClinOps Manager and clinical pharmacists
• Utilize internal tools and reporting to effectively perform job duties (e.g. Tredium, JMT)
• Serve as experts on adjudication system (e.g., claims processing, clinical review support)
• Collaboratively work with other internal EmpiRx Health teams for needed support (e.g., Client Management and Call Center)

Qualifications

• Minimum 5 years of pharmacy experience
• Certified Pharmacy Technician
• Strong customer service orientation and commitment to delivering concierge-level service
• Ability to work in a fast-paced environment
• Time management skills with ability to meet tight deadlines
• Excellent verbal and written communication skills
• Proficient in Microsoft Office Suite

Requirements

• College Degree Preferred

Benefits

• Paid Time Off
• 401(k) program
• Health Insurance including Dental & Vision coverage
• Tuition Reimbursement
• Health Savings Account
• Employee Assistance Program

Work Environment

• Remote