Clinical Operations Specialist

Clinical Operations Specialist

EmpiRx Health is the leading clinically-driven pharmacy benefits management company. As the pioneer in value-based pharmacy care, EmpiRx Health puts its customers and members first by enabling them to take control of their pharmacy benefits, healthcare outcomes, and financial results.

We place more emphasis on member care than any other PBM by focusing on health outcomes first. Our pharmacists and clinicians are at the center of everything we do―and our population health solution delivers tailored strategies for our clients. Leveraging our newly launched, AI-powered pharmacy care platform, Clinically™, EmpiRx Health’s pharmacists and client experience teams provide the highest quality pharmacy care to our clients and their members. This enables benefits plan sponsors to keep their members healthy, happy, and productive, while substantially reducing prescription drug spending, which has been on an explosive growth trajectory in recent years.

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.

If you are a highly motivated Clinical Operations Specialist with robust administrative support experience related to pharmacy adjudication processes and clinical review procedures and are eager to make a meaningful impact in the healthcare industry, we encourage you to apply.

Key Responsibilities:

• 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)

Required Qualifications & Experience:

• 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

Preferred Qualifications: (not needed if internal)

• College Degree Preferred

SHIFT IS M-F 10:30am - 7pm

Work Environment: Remote

Total earnings may also include various incentive options. Actual pay will be adjusted based on experience, education, geographic location, and other job-related factors as permitted by law. Subject to program eligibility, this position qualifies for a robust suite of benefits including: Paid Time Off, a 401(k) program, Health Insurance including Dental & Vision coverage, Tuition Reimbursement, Health Savings Account, and an Employee Assistance Program.

EmpiRx Health is an Equal Opportunity Employer

At EmpiRx Health, we wholeheartedly embrace the power of diversity and the magic of inclusion. The kaleidoscope of unique perspectives, backgrounds, and talents fuels our innovation and sets us apart. We're on a mission to build a team as diverse as the world we serve, where everyone is welcome and celebrated. We're not just breaking down barriers; we're actively erasing them to create an environment where opportunity knows no bounds. In unity, we find our strength and invite individuals from all walks of life to join us in our exhilarating journey to shape a brighter, more inclusive future together.