Pharmacy Benefits Liaison & Audit Specialist

WPS Health Solutions; Detroit (MI); Hybrid; USD 75,000 - 78,000; Full time

Benefits offered by this job

Remote & hybrid options

Performance bonus

401(k) match

Health/dental/telehealth from Day 1

Professional development programs

Job summary

WPS Health Solutions seeks a Pharmacy Coordinator to oversee audit processes for delegated PBM activities and build expertise in the PBM's online claims system. You will act as a subject-matter expert for internal teams handling escalated issues and help resolve complex claims and performance gaps.

You will collaborate with Call Center, Sales, and Health Services to improve educational materials, coordinate employer group reporting, and support vendor discussions.

Qualifications

• High school diploma and work-related experience.
• 5+ years in a Pharmacy Benefit role for a Health Insurer, PBM, or equivalent.
• Knowledge of health benefits carrier concepts, PBM operations, terminology, and regulatory standards (URAC, CMS).
• Understanding of pharmacy claims processing, formulary management, and utilization review workflows.
• Excellent communication and strong relationship management skills with internal and external partners.
• Strong analytical and problem-solving skills.
• Strong attention to detail and ability to manage multiple priorities.

Responsibilities

• Serve as the primary subjectmatter expert for internal teams on pharmacy benefits and system capabilities.
• Interpret pharmacy claims and utilization data, evaluate trends, and address issues or performance gaps.
• Make decisions regarding PBM operational needs and partner with PBM to maintain performance-monitoring processes.
• Collaborate with Call Center, Sales, Account Management, Marketing, and Health Services to create effective educational materials.
• Coordinate PBM employer group reporting and support external customer discussions.
• Work with Risk Management to evaluate high-cost claims and determine actions for denials.
• Assist Plan Product with mask configuration and system updates in partnership with PBM.
• Coordinate with PBM and vendors to gather materials for QIC presentations and reviews.
• Quantify savings and outcomes for pharmacy programs and identify cost-reduction opportunities.
• Other duties as assigned

Skills

Communication

Analytical skills

Problem solving

Attention to detail

Multitasking

Education

Associate's degree in business/healthcare

High school diploma

Job description

WPS Health Solutions seeks a Pharmacy Coordinator to oversee audit processes for delegated PBM activities and build expertise in the PBM's online claims system. You will act as a subject-matter expert for internal teams handling escalated issues and help resolve complex claims and performance gaps.

You will collaborate with Call Center, Sales, and Health Services to improve educational materials, coordinate employer group reporting, and support vendor discussions.