Pharmacy Benefits & Audit Lead (Hybrid/Remote)

WPS Health Solutions; Minneapolis (MN); Hybrid; USD 75,000 - 78,000; Full time

Benefits offered by this job

Remote and hybrid work options

Performance bonus

401(k) with match

Health insurance DAY 1

Paid time off

Professional & Leadership Development

Job summary

WPS Health Solutions is seeking a Pharmacy Coordinator to oversee audit processes for delegated PBM activities and to become a subject matter expert on the PBM’s online claims system. You will guide internal teams and resolve escalated customer issues by interpreting claims, evaluating trends, and determining actions.

The role involves collaboration across departments to maintain performance-monitoring processes, support education materials, and quantify cost-saving opportunities for pharmacy

Qualifications

• High school diploma and related experience required.
• 5+ years in a Pharmacy Benefit role for a health insurer or PBM.
• Knowledge of health benefits carrier concepts and PBM operations.
• Understanding of pharmacy claims processing and formulary management.
• Excellent communication and relationship management skills.
• Strong analytical, problem-solving and prioritization abilities.

Responsibilities

• Serve as the primary SME for pharmacy benefits and system capabilities.
• Interpret pharmacy claims, evaluate trends, and address issues.
• Decide PBM operational needs and monitor performance processes.
• Collaborate with Call Center, Sales, Account Management, Marketing, and Health Services to improve materials.
• Coordinate employer group reporting and support discussions with external customers.
• Work with Risk Management to evaluate high-cost claims and denials.
• Assist Plan Product with mask configuration and PBM system updates.
• Coordinate with PBM and vendors for Quality Improvement Committee materials.
• Quantify savings and outcomes for pharmacy programs and identify improvements.
• Perform other duties as assigned.

Skills

Communication

Analytical thinking

Attention to detail

Multitasking

Interpersonal skills

Education

High school diploma

Associate's degree in business/healthcare

Job description

WPS Health Solutions is seeking a Pharmacy Coordinator to oversee audit processes for delegated PBM activities and to become a subject matter expert on the PBM’s online claims system. You will guide internal teams and resolve escalated customer issues by interpreting claims, evaluating trends, and determining actions.

The role involves collaboration across departments to maintain performance-monitoring processes, support education materials, and quantify cost-saving opportunities for pharmacy