Pharmacy Services Specialist

Motion Recruitment; Durham (NC); Remote; USD 85,000 - 110,000; Full time

Job summary

Motion Recruitment is seeking a Pharmacy Services Specialist to support pharmacy benefit management operations remotely in North Carolina. The role focuses on coordinating PBM activities, RX claims, and prior authorization processes while serving as a subject matter expert for related initiatives.

You will collaborate with internal teams and external partners to resolve issues, manage contract workflows, and ensure compliance across programs.

Qualifications

• 5+ years of experience in a related field within health insurance or PBM.
• Experience with RX claims and prior authorization processes.
• Strong problem-solving and collaboration across internal and external teams.

Responsibilities

• Coordinate daily activities related to pharmacy benefit management operations.
• Support staff and coordinate tasks for programs, projects and initiatives.
• Serve as a subject matter expert for assigned initiatives and their impact on pharmacy needs.
• Resolve issues and escalate to management as appropriate; assist with clinical and contractual issues.
• Coordinate review, implementation, and QA of benefit plan administration with stakeholders and PBM team.
• Resolve or coordinate pharmacy claim adjustments and escalated customer inquiries with PBM and internal teams.
• Coordinate resolution of Pharmacy Coverage Determinations with Clinical Staff and external partners.
• Coordinate resolution of claim reconsiderations and appeals with Appeals department or partners.
• Respond to and coordinate review of RFPs, government applications and similar requests.
• Develop sourcing documents (RFP, RFI, RFQ) and manage status reporting for sourcing activities.
• Analyze market dynamics and share knowledge within portfolio of products and services.
• Partner with stakeholders to source products and services using analytics to drive results.
• Evaluate sourcing results from total cost of ownership and provide optimization recommendations.
• Participate in cross-functional teams for complex vendor negotiations and risk mitigation.
• Review and lead supplier relationship management within assigned category.
• Build relationships with vendor personnel and drive engagement.
• Coordinate vendor reviews and develop yearly vendor plans for assigned vendors.
• Coordinate vendor risk assessments and develop remediation plans.

Skills

PBM experience

Pharmacy operations

RX claims

Pharmacy technician

Prior authorization

Vendor management

Job description

Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for a Pharmacy Services Specialist.They have over 4 million customers and 5,000+ employees dedicated toproviding innovative solutions that simplify the healthcare system, improve efficiency and outcomes while reducing costs.

Location: remote in NC

Required Skills:

• 5+ years of experience in related field
• PBM exp, Hard wired internet

• RX claims
• Pharmacy technician
• prior authorization (retail)

What you will be doing:

• Provides daily coordination of activities related to operations of pharmacy benefit management.
• Provides support to staff and coordinates tasks regarding the research, development, implementation and evaluation of programs, projects and initiatives.
• Serves as resource to staff and subject matter expert for assigned initiatives to provide input regarding pharmacy needs, impacts and projects.
• Resolves issues and escalates to management as appropriate; assists management in addressing clinical and contractual issues.
• Coordinates review, implementation, and quality assurance of benefit plan administration with internal stakeholders and PBM account team.
• Resolves or coordinates the resolution of escalated customer service inquiries and grievances internally and with PBM, including researching and authorizing/making pharmacy claim adjustments as appropriate.
• Coordinates the resolution of Pharmacy Coverage Determinations with Clinical Staff and/or external partners as appropriate
• Coordinates the resolution of pharmacy claim reconsiderations and appeals with the Appeals department and/or external partners as appropriate.
• Responsible for responding to and coordinating review and approval of RFPs, government program applications, and similar requests.
• Conduct sourcing events, including development of project work plan, category profile, category strategy, minimum requirements and evaluation criteria, solicitation
• Develop and implement assorted bid documents and requests (i.e. RFP, RFI, RFQ); and manage status reporting and performance metrics of sourcing and category management activities.
• Understand, analyze and forecast complex market and industry dynamics and share subject matter expertise and industry knowledge within the established portfolio of products and services.
• Partner with stakeholders to source products and services using proven tools, processes, and analytics to drive and achieve business results.
• Evaluate analyses of sourcing results from a total cost of ownership perspective and provide optimization recommendations
• Participate in cross-functional teams responsible for complex vendor negotiations, including those that require specialized subject matter expertise, nonstandard risk mitigation solutions, and coordination of multiple arrangements.
• Review and lead supplier relationship management and performance within an assigned category
• Proactively establish and foster successful, positive working relationships with vendor personnel. Drive vendor engagement through formal and informal transactions.
• Engage stakeholders to implement and execute vendor relationship management plan.
• Coordinate and host vendor business reviews
• Develop, track and manage yearly vendor plans for assigned vendors within the assigned category(ies) and ensure vendor compliance.
• Coordinate vendor risk assessments and develop plans to track and address significant risks.
• Serve as an escalation point for the business in resolving vendor performance issues. issue resolution.
• Manage contracts and collaborate effectively with Corporate Compliance, Legal, Audit and Risk Management and other internal stakeholders for compliance activities to ensure regulatory conditions are met.
• Research, analyze and provide data driven recommendations regarding compliance or audit level issue resolution and remediation.
• Facilitate and monitor vendor implementation of relevant corrective action plans.
• Develop new procedures, training, initiatives, specifications and recommendations for process or policy changes and improvements, as appropriate.

****To be eligible to contract at this client you must be able to pass a drug test and criminal background check