Pharmacy Vendor Strategy & Audit Lead (Hybrid/Remote)

WPS Health Solutions; Madison (WI); Hybrid; USD 75,000 - 78,000; Full time

Benefits offered by this job

Remote options

Hybrid work two days a week

Bonus opportunities

PTO

Job summary

WPS Health Solutions is seeking a Pharmacy Coordinator in Madison, WI to oversee audit processes for delegated PBM activities and build expertise in the PBM online claims system. The role acts as a knowledgeable resource for internal teams resolving escalated customer issues.

The position emphasizes strong analytical skills, healthcare benefits knowledge, and collaboration with multiple departments to improve performance and guide PBM operations.

Qualifications

• Knowledge of health benefits carrier concepts, PBM operations, and regulatory standards (URAC, CMS).
• Experience interpreting pharmacy claims, utilization data, and formulary management.
• Excellent communication and strong relationships with internal and external partners.

Responsibilities

• Serve as the primary subjectmatter expert for internal teams on pharmacy benefits and PBM capabilities, guiding actions for escalated issues.
• Interpret pharmacy claims and utilization data, evaluate trends, and determine actions to address performance gaps.
• Make decisions regarding PBM operational needs and maintain performance-monitoring processes with PBM.
• Collaborate with Call Center, Sales, Account Management, Marketing, and Health Services to improve educational materials.
• Coordinate PBM employer group reporting and support external customer discussions.
• Work with Risk Management to evaluate high-cost claims and actions for denials.
• Assist Plan Product with system updates and PBM partnering on benefit changes.
• Coordinate with PBM and vendors to prepare materials for Quality Improvement Committee reviews.
• Quantify savings/outcomes for programs and identify cost-reduction opportunities.
• Other duties as assigned

Skills

Pharmacy benefit knowledge

Analytical skills

Communication

Relationship management

Problem-solving

Attention to detail

Education

High school diploma

Associate's degree in business/healthcare

Tools

PBM claims system

Job description

WPS Health Solutions is seeking a Pharmacy Coordinator in Madison, WI to oversee audit processes for delegated PBM activities and build expertise in the PBM online claims system. The role acts as a knowledgeable resource for internal teams resolving escalated customer issues.

The position emphasizes strong analytical skills, healthcare benefits knowledge, and collaboration with multiple departments to improve performance and guide PBM operations.