Client Operations Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee the management of texts, service emails, incoming calls, and voicemail.

• Act as a point of escalation for Helpdesk issues, assisting with calls and inquiries that are not addressed by Helpdesk agents.

• Maintain and refresh Helpdesk instructions and procedures as necessary.

• Address inquiries regarding prior authorization status from providers and partner vendors.

• Resolve questions related to member coverage, costs, cards, and clinical criteria for prior authorizations.

• Print and dispatch prior authorization denial letters to the relevant parties.

• Assist members with portal registration and claims viewing for their dependents.

• Enter rejection overrides and support pharmacies with claim adjudication processes.

• Review and prioritize prior authorization tickets, eliminate duplicates, and archive inactive or outdated tickets.

• Update provider fax details and resend prior authorization forms or decision faxes as required.

• Coordinate the collection of data for new accounts and renewals.

• Prepare documentation for implementation, plan changes, legal matters, account structure, and drug/product lists.

• Conduct claims testing to ensure the accuracy of configurations.

• Participate in weekly client meetings and monitor ongoing issues.

• Maintain records for portal access, invoices, reports, and rebate recipients.

• Provide portal tutorials and address report discrepancies.

• Collaborate with the Marketing team to create client-facing lists and materials.

• Deliver census files and member contact information to partners and vendors.

• Send summaries of prior authorization approvals and rejections to partners and vendors.

• Inform clients and agents about formulary changes and their implications for members.

• Review invoices, complete clinical reports, and generate custom reports as necessary.

• Analyze reimbursement requests and disputed claims for eligibility and programming precision.

• Investigate discrepancies in accumulators and issues within eligibility files.

• Submit corrections for eligibility and refund reports to the appropriate teams.

⛳️ Requirements

• Prior experience in pharmacy benefits, PBM operations, health plan administration, or a similar account/client support position is preferred.

• High attention to detail and accuracy, especially in data entry, claims processing, and configuration tasks.

• Exceptional written and verbal communication abilities.

• Capability to manage multiple queues, tickets, and deadlines concurrently.

• Proficiency with spreadsheets, data files, and basic reporting tools.

• Strong problem-solving aptitude with the ability to research and resolve discrepancies independently.

• Ability to work collaboratively across various internal teams.

• Role primarily sedentary; must be able to perform some standing, walking, bending, and reaching activities.

• Competence in using standard office equipment, including computers, mice, keyboards, printers, copiers, phones, and other related tools.

🏝️ Benefits

• Remote-first team environment.

• Supportive culture that encourages employees to bring their authentic selves to work.

• Opportunities for personal and professional growth alongside colleagues.

• Minimal travel may be required.