Position Purpose: This role will focus on ensuring that the administration of the pharmacy program is accurate and compliant by supporting various operational tasks. This role will serve as the subject matter expert supporting various pharmacy operations tasks including but not limited to claims, formulary, benefit, and networks.
Key Details: This is a remote, day-shift position working Monday through Friday with a start time between 8:00 AM and 9:00 AM Eastern or Central Time. In this role, you will be responsible for supporting PBM oversight and internal activities related to pharmacy fraud, waste, and abuse (FWA), as well as pharmacy audit functions. Some key recurring tasks include joining PBM operational calls to support the follow-up and resolution of open items related to the department and implementing and maintaining accurate and compliant member and provider communication processes for Pharmacy FWA-related communications through the PBM and/or internal processes. You will partner with internal teams, health plans,
and PBM partners to support member and provider communications, regulatory reporting, operational metrics, and pharmacy network activities. This role is responsible for ensuring accurate, timely, and compliant processes while supporting issue resolution, documentation updates, and ongoing process improvement initiatives. The idóneo candidate brings managed care experience working with pharmacy claims or PBM data, strong attention to detail, excellent organizational and communication skills, and the ability to manage multiple priorities independently. Advanced Excel skills, experience with tools such as Power BI and/or Power Automate, and strong data analysis skills would be beneficial in this role and are used to support reporting and analytics.
Ability to conduct data analysis to support operations and exercise independent judgement
Provides support for escalated issues and special projects as assigned
Conduct UAT to ensure that systems reflect
📌 Pharmacy Operations Specialist II (Valparaíso)
🏢 Centene
📍 Valparaíso
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