Pharmacy Claims Review Manager

Consonus Healthcare; Portland (OR); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Paid training and career advancement

Education stipend $25,000

Generous PTO

Medical/Dental/Vision insurance

MDLIVE access

401K with employer match

Employee Assistance Program

Job summary

Consonus Pharmacy is seeking a Pharmacy Claims Review Manager to oversee all processing operations, including adjudication, third-party billing, and reimbursement optimization. You will lead a team ensuring accurate submissions, resolving claim exceptions, and maintaining payer compliance.

The role focuses on coordinating with Billing, Customer Accounts, and Pharmacy Operations to optimize reimbursement in a long-term care setting, with opportunities for professional growth.

Qualifications

• Bachelor's degree required or equivalent experience.
• 5+ years in pharmacy claims, third-party billing, or PBM operations.
• 2+ years of supervisory or management experience.
• Strong knowledge of NCPDP standards, Part D, Medicaid, and PBMs.

Responsibilities

• Oversee all pharmacy claims processing operations, including adjudication and reimbursement optimization.
• Lead a team to ensure accurate and timely claim submission and minimize write-offs.
• Ensure compliance with PBM, Medicare Part D, Medicaid, and commercial payer requirements.

Skills

Leadership

Analytical thinking

Under pressure

Education

Bachelor's degree in Healthcare Administration, Business, Finance, or related field

Equivalent experience considered

Tools

Pharmacy management systems

Reporting tools

Job description

Pharmacy Claims Review Manager

What’s your wish list for the perfect job? Maybe it’s to make a

What’s your wish list for the perfect job? Maybe it’s to make a positive impact in the world, or to grow your career in healthcare. Maybe working with a supportive team is top priority, or to feel respected and valued. If your answer is “all of the above,” consider joining our team at Consonus Pharmacy. It’s a perfect opportunity for compassionate people dedicated to people’s health and well-being. Consonus Pharmacy is a closed-door long-term care pharmacy specializing in the needs of nursing facilities, assisted living residents, and their caregivers. We are currently hiring a Pharmacy Claims Review Manager to join our team! As the Pharmacy Claims Review Manager your responsibilities will include (but are not limited to): The Pharmacy Claims Manager is responsible for overseeing all pharmacy claims processing operations, including prescription adjudication, third-party billing, claim rejection management, and reimbursement optimization. This position leads a team responsible for ensuring accurate and timely claim submission, resolution of claim exceptions, compliance with PBM, Medicare Part D, Medicaid, and commercial payer requirements, and adherence to NCPDP standards. The Pharmacy Claims Manager partners closely with Billing, Customer Accounts, and Pharmacy Operations to ensure accurate reimbursement and compliance, minimize claim write-offs, and ensure exceptional service to residents, facilities, and payers. In our Long-Term Care environment, there is focus on coordination with the Credentialing & Contracting team on payer enrollment issues, and management of LTC-specific reject queues related to transition fills, hospice billing, and facility census changes.

Some Benefits May Include

• Paid training & career advancement opportunities
• $25,000 toward ongoing education benefit
• Generous Paid Time Off that pools vacation, sick & holiday pay in a single bucket for flexible use
• Medical/Dental/Vision insurance
• Free access to MDLIVE - allowing access to your health benefits from anywhere
• 401K With Employer Match
• Employee Assistance Program: with free access to counseling & support services

Qualifications

• Bachelor's degree in Healthcare Administration, Business, Finance, or related field; equivalent experience considered.
• Minimum 5 years of pharmacy claims, third-party billing, pharmacy revenue cycle, or PBM operations experience. Long - Term Care experience preferred.
• Minimum 2 years of supervisory or management experience.
• Strong understanding of: NCPDP claim standards, Medicare Part D, Medicaid pharmacy billing, Managed Care reimbursement, PBM claim adjudication processes, Pharmacy revenue cycle operations.
• Experience working with PBMs such as Express Scripts, CVS Caremark, OptumRx, Humana, Prime Therapeutics, MedImpact, and Navitus.
• Experience managing Medicare Part D, Medicaid, and dual-eligible populations
• Advanced analytical and problem-solving skills.
• Proficiency with pharmacy management systems and reporting tools
• Ability to work under pressure in fast-paced environment ensuring timely and accurate billing
• Ability to travel to other pharmacy locations as required
• Certified Pharmacy Technician (CPhT) preferred (can obtain after hire)

EEO Statement

“Be here. Be you.” For more than 30 years, Marquis Companies and Consonus Healthcare have been serving seniors and welcoming staff of all backgrounds, skills, and perspectives. The Marquis family of companies offer a rich heritage of embracing differences and honoring individuality. We’ve continued to grow in our appreciation of diversity in the workplace. We know it builds strength, drives innovation, and brings valuable new perspectives and energy. We’re committed to making our workforce an even greater reflection of the people and communities we serve, and we are honored our employees have chosen to work at Marquis and Consonus. Everything we do as a company is driven by our mission to help those we serve, and each other, live the best rest of our lives. That means you being you - without apology or compromise. We value your every uniqueness and continue to curate, nurture, and sustain an inclusive culture. It’s the foundation of who we are and the evolution of our collective future.