Pharmacy Claims SME

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.



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*Please note that this Position is contingent upon winning award

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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.

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