Clinical Ops Specialist — Adjudication & PAs

EmpiRx Health, LLC.; Montvale (NJ); On-site; USD 51,000 - 64,000; Full time

Benefits offered by this job

Paid Time Off

401(k) program

Health Insurance

Dental & Vision

Student Loan Reimbursement

Health Savings Account

Employee Assistance Program

Job summary

EmpiRx Health is seeking a Clinical Operations Specialist to provide administrative and operational support to adjudication and clinical review teams on-site in Montvale, NJ. The role focuses on processing claim overrides and PAs with strict adherence to SOPs and SLA targets.

The ideal candidate has 5+ years of pharmacy experience, including claims adjudication and prior authorization, and strong MS Office skills.

Qualifications

• Minimum 5 years of pharmacy experience, including at least 2 years in claims adjudication and 2 years in prior authorization processes.

Responsibilities

• Provide efficient administrative and operational support to adjudication, prior authorization, and clinical review teams.
• Accurately process claim overrides and case documentation in accordance with SOPs.
• Ensure compliance with all turnaround times and quality metrics to meet member and client expectations.
• Assist clinical pharmacists and operations teams with workflow management and reporting needs.
• Meet established case completion targets and adhere to a 2-hour SLA for escalation requests.
• Proactively monitor case queues to ensure timely follow-up and resolution.
• Escalate high-priority or complex issues promptly to leadership.
• Collaborate with clinical pharmacists, call center representatives, and internal stakeholders for efficient communication.
• Partner with Member Services and Client Management to deliver exceptional service.
• Maintain a proactive and solutions-focused approach in all interactions.

Skills

Pharmacy experience

Claims adjudication

Prior authorization

Customer service

MS Office

Education

High school diploma

Tools

Microsoft Office

Job description

EmpiRx Health is seeking a Clinical Operations Specialist to provide administrative and operational support to adjudication and clinical review teams on-site in Montvale, NJ. The role focuses on processing claim overrides and PAs with strict adherence to SOPs and SLA targets.

The ideal candidate has 5+ years of pharmacy experience, including claims adjudication and prior authorization, and strong MS Office skills.