Pharmacy Benefits & PBM Audit Lead (Hybrid)

WPS Health Solutions; Hampton (VA); Hybrid; USD 75,000 - 78,000; Full time

Benefits offered by this job

Remote and hybrid options

Performance bonus

401(k) with match

Paid time off

Health/dental/telehealth

Leadership development

Job summary

WPS Health Solutions is seeking a Pharmacy Coordinator to oversee audit processes for PBM delegated activities and develop expertise in the PBM's online claims system. You will resolve escalated customer issues with internal teams and drive process improvements in a hybrid work model.

The role requires 5+ years in a Pharmacy Benefit role, strong analytics, and collaboration across departments to design effective educational materials and reporting for employer groups.

Qualifications

• High school diploma and work-related experience.
• 5+ years in a Pharmacy Benefit role, working for a Health Insurer, PBM, or equivalent.
• Knowledge of health benefits carrier concepts, PBM operations, terminology, and regulatory standards (URAC, CMS, state).
• Understanding of pharmacy claims processing, formulary management, and basic 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, guiding internal teams and resolving escalated issues.
• Interpret pharmacy claims and utilization data, evaluate trends, and determine actions to address issues.
• 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 enhance educational materials.
• Coordinate PBM employer group reporting and support external customer discussions with trend analyses and guidance.
• Work with Risk Management to evaluate high-cost claims and actions for Short Term Health Plan denials.
• Assist Plan Product and related departments with system updates and PBM partnerships.
• Coordinate with PBM and pharmacy vendors for presentations to QIC and audit reviews.
• Quantify savings and outcomes for pharmacy programs and identify cost-reduction opportunities.
• Other duties as assigned

Skills

Pharmacy Benefits

Data interpretation

Stakeholder management

Communication

Analytical 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 PBM delegated activities and develop expertise in the PBM's online claims system. You will resolve escalated customer issues with internal teams and drive process improvements in a hybrid work model.

The role requires 5+ years in a Pharmacy Benefit role, strong analytics, and collaboration across departments to design effective educational materials and reporting for employer groups.