Clinical Operations Specialist

EmpiRx Health; United States; On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Paid Time Off

401(k) program

Health Insurance including Dental & Vision coverage

Tuition Reimbursement

Health Savings Account

Employee Assistance Program

Employee Assistance Program

Job summary

A leading pharmacy benefits management company is seeking a Clinical Operations Specialist to ensure high-quality member support in pharmacy services. The ideal candidate will have at least 5 years of pharmacy experience, demonstrating strong customer service skills in a fast-paced environment. Responsibilities include managing clinical reviews and adjudication processes while collaborating with internal teams. This position offers competitive benefits and a dynamic work atmosphere where you can make a meaningful impact.

Qualifications

• Minimum 5 years of pharmacy experience.
• Strong customer service orientation.
• Ability to work in fast-paced environments.
• Strong time-management and meeting tight deadlines.
• Excellent verbal and written communication skills.
• Proficient in Microsoft Office Suite.

Responsibilities

• Deliver white-glove service excellence.
• Serve as account support for adjudication matters.
• Ensure daily processes are followed.
• Assist Client Management with overrides and related issues.
• Collaborate with Care Management teams for overrides and reviews.
• Follow daily processes and KPI-driven tasks.
• Support PA intake, documentation, and communication oversight.
• Handle escalation requests within defined timeframes.
• Complete worklists to meet KPI standards.
• Operate under ClinOps Manager and pharmacists supervision.
• Utilize internal tools (e.g., Tredium, JMT) for duties.
• Be an expert on adjudication systems (claims processing, reviews).
• Collaborate with internal teams for necessary support.

Skills

Customer service orientation

Time management

Communication skills

Microsoft Office Suite

Education

College Degree (preferred)

Tools

Tredium

JMT

Job description

Clinical Operations Specialist – EmpiRx Health

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
• 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

• College Degree Preferred

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.