Pharmacy Operations Lead

Triple-S Management Corp.; San Juan (PR); Sur place; USD 52 000 - 76 000; Plein temps

Résumé du poste

Triple-S Management Corp. seeks an experienced operations professional to oversee physician-administered drugs (PADs) across Commercial, Medicare, and Medicaid.

You will manage caseloads, assignments, and regulatory compliance while serving as an internal SME and administrative backbone for high-quality service delivery. You will monitor performance metrics, support SOP updates, and coordinate with Clinical, Claims, PBM, and Provider Relations teams to resolve issues and drive process

Qualifications

• Bachelor’s degree and 3–5 years in administrative/office roles.
• Experience with Medicaid/Commercial/Medicare environments is a plus.
• Familiarity with CMS, URAC or similar regulatory standards is desirable.

Responsabilités

• Oversee daily PAD-related workflows across all lines of business.
• Support caseload management, case assignments, and queue balancing.
• Monitor KPIs, generate regulatory and operational reports for leadership.
• Assist in SOP development and maintenance for PAD workflows.
• Coordinate with Provider Relations, Claims, PBM and Clinical Teams.
• Maintain documentation and update procedures and templates.
• Follow up on actions and ensure completion and compliance.

Connaissances

Case Management

Regulatory Reporting

Quality Assurance

SOP Development

Cross-functional Collaboration

Formation

Bachelor's Degree in Business Administration

Description du poste

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

JOB SUMMARY

Plays a crucial role in overseeing the day-to-day operational workflows surrounding physician-administered drugs (PADs) across all lines of business (Commercial, Medicare, and Medicaid). Working closely with the Pharmacy Supervisor, this individual is responsible for caseload management, case assignments, operational monitoring, and compliance oversight. The role serves as an internal subject matter expert and administrative backbone to ensure seamless execution, regulatory compliance (CMS, local regulations, and URAC standards), and high-quality service delivery.

ESSENTIAL FUNCTIONS

• Monitor daily operational activities across Medicaid, Commercial, and Medicare Advantage.
• Caseload Review & Case Management Support:
  Workflow Tracking: Continuously review incoming and active caseloads for physician-administered drug pre-authorizations, claims reviews, and utilization management queues.
  Queue Balancing: Monitor real-time volume shifts across Commercial, Medicare, and Medicaid lines of business to prevent bottlenecks and backlogs.
  Complex Case Escalation: Identify high-risk or complex clinical cases and route them appropriately to clinical staff or supervisors while maintaining tracking protocols.
• Monitoring, Oversight & Reporting:
  Performance Metrics: Monitor operational dashboards, track key performance indicators (KPIs), and evaluate individual and team productivity.
  Support Supervisor and other areas on Regulatory Reporting: Generate routine and ad-hoc compliance, operational, and audit reports detailing processing volumes, approval/denial trends, and TAT compliance for executive review.
• Quality Assurance: Conduct regular internal audits of processed cases to verify accuracy, consistency, and alignment with operational and medical policy.
• Support supervisor with SOP development and maintenance: support or execute writing, updating, and maintaining Standard Operating Procedures (SOPs) for physician-administered drug workflows as medical policies change.
• Coordinate the preparation, processing, tracking, and distribution of pharmacy-related letters and correspondence for Physician administered Drugs.
• Manage special letter projects, mass mailings, and line-of-business communication initiatives for Physician Administered Drugs.
• Cross-Functional Collaboration: Coordinate with Provider Relations, Claims, Pharmacy Benefits Management (PBM), and Clinical Teams to resolve operational roadblocks.
• Manage, execute and monitor special projects and initiatives that impact multiple lines of business.
• Assist in identifying operational gaps, workflow inefficiencies, and training needs; recommend process improvements to streamline PAD handling.
• Maintain organized documentation related to assigned Pharmacy processes.
• Manage and execute updating procedures, workflows, templates, and operational documents.
• Ensure effective follow-up and follow-through of assigned activities, pending requests, and operational issues through completion.
• Perform any additional duties assigned by Supervisor or Manager.

EDUCATION

• Bachelor's Degree in Business Administration or Health

EXPERIENCE

Bachelor’s Degree, preferably in Business Administration or health related field and Pharmacy Technician Course. Three to five years of experience in office tasks, or equivalent experience in administrative roles.

LICENSES AND CERTIFICATIONS

• None required

COMPETENCIES

• Action Oriented
• Manages Ambiguity

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.