Job Description
We are looking for a passionate and dedicated Manager of Clinical Operations to lead and optimize clinical coding processes, benefit setups, and regulatory compliance. This role offers the opportunity to directly impact the efficiency and success of clinical operations, working closely with a talented team to ensure exceptional outcomes for both clients and members. You'll play a pivotal role in driving implementations, maintaining high standards of compliance, and ensuring the ongoing success of formulary and benefit updates.
Key Responsibilities:
Team Leadership:
Onboard, train, and manage a dynamic team, promoting both professional growth and operational excellence.
Mentor staff members and conduct performance evaluations to ensure a high-performing team.
Develop and maintain department policies and procedures to drive consistency and efficiency.
Clinical Operations Oversight:
Supervise coding updates in the claims adjudication platform, ensuring seamless clinical benefit setups and formulary updates.
Ensure regulatory compliance with ACA/preventive drug lists and maintain up-to-date knowledge on changes.
Assess the impact of Medispan drug database changes on formulary and benefit setups.
Testing and Quality Assurance:
Lead the pre-testing and post-testing of formulary and benefit changes to ensure accuracy and functionality.
Address escalations and troubleshoot operational issues related to clinical coding and benefit setups.
Implementation Leadership:
Serve as the Clinical Implementations Coding Lead for new client onboarding and benefit implementation projects.
Collaborate with cross-functional teams to ensure timely and seamless project delivery.
Regulatory and Accreditation Compliance:
Support activities related to URAC accreditation, ensuring clinical operations meet quality and compliance standards.
Stay current with regulatory changes to ensure alignment with industry standards.
Qualifications:
Bachelor's degree in Pharmacy (required), with an advanced degree (PharmD, MBA) preferred.
Active and unrestricted Pharmacist license.
5+ years of experience in clinical operations, coding management, or related roles.
3+ years of leadership experience preferred.
Strong background in pharmacy benefit management (PBM) preferred.
Expertise in clinical benefit setups, coding processes, and regulatory compliance.
Familiarity with clinical coding systems and platforms, with proficiency in Microsoft Office Suite.
Strong analytical, problem-solving, and project management skills.
Experience with Medispan or First Data Bank terminology is a plus.
Knowledge of ACA/preventive drug list maintenance and URAC accreditation requirements.
Collaborative team player with the ability to manage cross-functional relationships.
Willingness to travel up to 10%.
What We Offer:
An opportunity to drive meaningful change within the pharmacy benefits management industry while improving patient outcomes.
A supportive work culture that thrives on collaboration and employee success.
Competitive compensation, equity options, and a comprehensive benefits package (health, dental, vision, life insurance).
Additional Information:
Remote employees are expected to maintain a professional work environment free from distractions, ensuring optimal performance and collaboration.
Equal Opportunity Employer:
We are committed to creating an inclusive and diverse workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, genetics, disability, age, or veteran status.
Employment Type: Full-Time
Salary: $ 115,000.00 Per Year
Job Tags
Full time,