Pharmacy Benefits & Audit Lead (Hybrid/Remote)

WPS Health Solutions; Omaha (NE); Hybrid; USD 75,000 - 78,000; Full time

Benefits offered by this job

Remote options

Hybrid work

Performance bonus

401(k) match

Paid time off

Health insurance

Dental insurance

Telehealth

Leadership programs

Job summary

WPS Health Solutions in Madison, WI, seeks a Pharmacy Coordinator to oversee PBM audit processes and develop expertise in the PBM online claims system.

The role serves as SME for internal teams to resolve escalated issues, interpret claims data, and drive performance improvements in pharmacy benefits.

Ideal candidates have 5+ years of PBM experience, strong analytical skills, and the ability to work in a hybrid/remote setup within approved states.

Qualifications

• High school diploma required; relevant work experience.
• 5+ years in a Pharmacy Benefit role for insurer or PBM.
• Knowledge of health benefits and PBM operations.
• Understanding of pharmacy claims processing and formulary management.
• Strong communication and relationship management with partners.
• Strong analytical, problem-solving and detail-oriented abilities.
• Associate's degree in business/healthcare (preferred).

Responsibilities

• Serve as primary subject matter expert on pharmacy benefits and system capabilities for internal teams.
• Interpret pharmacy claims data, evaluate trends, and determine actions for issues.
• Make decisions regarding PBM operational needs and monitor performance processes.
• Collaborate with Call Center, Sales, Account Management, Marketing, and Health Services.
• Coordinate PBM employer group reporting and support external discussions.
• Work with Risk Management on high-cost claims and denials.
• Assist Plan Product with PBM-related updates and system configurations.
• Coordinate with PBM and vendors for presentations to QIC.
• Quantify savings and outcomes for pharmacy programs and identify cost-reduction opportunities.
• Other duties as assigned.

Skills

Pharmacy benefits

Health benefits concepts

Pharmacy claims processing

Communication skills

Analytical skills

Detail orientation

Education

High school diploma

Associate's degree (preferred)

Job description

WPS Health Solutions in Madison, WI, seeks a Pharmacy Coordinator to oversee PBM audit processes and develop expertise in the PBM online claims system.

The role serves as SME for internal teams to resolve escalated issues, interpret claims data, and drive performance improvements in pharmacy benefits.

Ideal candidates have 5+ years of PBM experience, strong analytical skills, and the ability to work in a hybrid/remote setup within approved states.