Pharmacy Claims SME - United States - 27448 - Maximus

General information

Job Posting Title

Pharmacy Claims SME

Date

Friday, January 10, 2025

City

Remote

Country

United States

Working time

Full-time

Description & Requirements

Maximus is seeking a highly skilled and knowledgeable Pharmacy Claims Subject Matter Expert (SME) with a strong background in appeals and arbitration to join our team. The ideal candidate will have experience in managing pharmacy claim adjudication, resolving complex claim disputes, and providing expert guidance on pharmacy claims processes. This role requires the ability to review, analyze, and respond to appeals, as well as represent the organization in arbitration proceedings related to pharmacy claims. They are responsible for overseeing arbitration proceedings to resolve any dispute raised by carrier or pharmacy. This includes but is not limited to client communication, quality control, and case processing.

***Please note that this Position is contingent upon winning award***

Essential Duties and Responsibilities:

- Provide legal research, guidance, advice, leadership, and training to project staff, ensuring compliance with all project and client policies/procedures, laws, and regulations.

- Interact with the client regarding case decisions.

- Guide teams to ensure all major client/legal requirements are met and relevant documents are captured accurately.

- Provide self-directed legal support to the project leadership.

- Process and resolve high profile and complex cases.

- Manage direct reports, including hiring, setting monthly individual/team goals, and evaluating employee performance.

Experience with pharmacy claims and reimbursements required.

Experience using health care pricing benchmark data or other pharmacy pricing databases required.

Experience with pharmacy/PBM disputes and appeals.

Experience in prescription drug pricing dispute resolution and/or arbitration on behalf of State or federal government agencies strongly preferred.

Pharmacy Claims Management:

Serve as the primary point of contact for complex pharmacy claims issues, including adjudication and payment discrepancies.

Analyze pharmacy claims data and work closely with internal teams to resolve issues related to claim processing, coding, and payment errors.

Ensure compliance with regulatory requirements, industry standards, and company policies.

Appeals and Dispute Resolution:

Oversee and manage the entire appeals process for pharmacy claims, including reviewing appeals submitted by providers, members, or pharmacies.

Investigate, analyze, and resolve pharmacy claim disputes through a structured review process, ensuring a fair and timely resolution.

Communicate effectively with stakeholders, including providers, pharmacies, and members, to explain claim decisions and the rationale behind those decisions.

Training and Guidance:

Provide subject matter expertise and training to internal teams regarding pharmacy claims processes, appeals, and arbitration protocols.

Offer guidance and mentorship to junior staff in resolving complex claim issues and improving claims handling efficiency.

Stay current with industry trends, regulatory changes, and best practices related to pharmacy claims management.

Reporting and Analysis:

Develop and maintain reports on appeal outcomes, arbitration cases, and pharmacy claim trends to inform leadership decision-making.

Track performance metrics related to pharmacy claims resolution and dispute management.

Must currently and permanently reside in the Continental US

Minimum Requirements

- Juris Doctorate from an accredited law school required.

- 3-5 years of related professional experience.

EEO Statement

Active military service members, their spouses, and veteran candidates often embody the core competencies Maximus deems essential, and bring a resiliency and dependability that greatly enhances our workforce. We recognize your unique skills and experiences, and want to provide you with a career path that allows you to continue making a difference for our country. We’re proud of our connections to organizations dedicated to serving veterans and their families. If you are transitioning from military to civilian life, have prior service, are a retired veteran or a member of the National Guard or Reserves, or a spouse of an active military service member, we have challenging and rewarding career opportunities available for you. A committed and diverse workforce is our most important resource. Maximus is an Affirmative Action/Equal Opportunity Employer. Maximus provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disabled status.

Pay Transparency

Maximus compensation is based on various factors including but not limited to job location, a candidate's education, training, experience, expected quality and quantity of work, required travel (if any), external market and internal value analysis including seniority and merit systems, as well as internal pay alignment. Annual salary is just one component of Maximus's total compensation package. Other rewards may include short- and long-term incentives as well as program-specific awards. Additionally, Maximus provides a variety of benefits to employees, including health insurance coverage, life and disability insurance, a retirement savings plan, paid holidays and paid time off. Compensation ranges may differ based on contract value but will be commensurate with job duties and relevant work experience. An applicant's salary history will not be used in determining compensation. Maximus will comply with regulatory minimum wage rates and exempt salary thresholds in all instances.