Manager, Clinical Operations

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AffirmedRx, a Public Benefit Corporation

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PBM • Pharmacy Benefit Management • Healthcare Analytics • Healthcare • Pharmaceuticals

11 - 50 employees

⚕️ Healthcare Insurance

Description

• AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. • Join us in improving health care outcomes for all! • The Manager, Clinical Operations will oversee the management and optimization of clinical coding processes, benefit setups, and regulatory compliance while ensuring a high level of team performance. • This role will drive efficient implementations, maintain compliance standards such as URAC accreditation, and support formulary and benefit updates to enhance client and member satisfaction. • Onboard, train, and manage staff, including clinical coding team members, fostering professional growth and operational excellence. • Provide mentorship and performance evaluations to maintain a high-performing team. • Create, maintain, and update department policies and procedures. • Oversee coding updates in claims adjudication platform and ensure accurate implementation of clinical benefit setups and formulary updates. • Manage and monitor the maintenance of ACA/preventive drug lists to ensure compliance with regulatory requirements. • Assess Medispan drug database changes and impact on formulary and benefit setup. • Supervise pre-testing and post-testing of formulary and benefit changes to ensure accuracy and functionality before deployment. • Troubleshoot and resolve escalations related to clinical coding, benefit setups, and other operational issues. • Serve as the Clinical Implementations Coding Lead for new client onboarding and benefit implementation projects. • Coordinate with cross-functional teams to deliver seamless and timely implementations. • Support and manage activities related to URAC accreditation, ensuring clinical operations meet quality and compliance standards. • Stay updated on regulatory changes and ensure processes align with industry standards.

Requirements

• Bachelor's degree in Pharmacy required • Advanced degree (PharmD, MBA) preferred • Active and unrestricted Pharmacist license, not state specific • 5+ years of experience in clinical operations, coding management, or related roles • 3 years in a leadership position preferred • 3+ years of experience in pharmacy benefit management (PBM) preferred • Proven expertise in managing clinical benefit setups, coding processes, and regulatory compliance • Proficiency with clinical coding systems and platforms • Strong analytical and problem-solving skills, with experience in testing and validating benefit setups • Excellent project management skills, including the ability to lead cross-functional teams and manage escalations • Familiarity with Medispan or First Data Bank terminology preferred • Proficiency in Microsoft Office Suite • Deep understanding of ACA/preventive drug list maintenance and URAC accreditation requirements • Ability to work collaboratively with cross-functional teams • Willingness and ability to travel (up to 10%)

Benefits

• Competitive compensation, including equity, with health, dental vision and other benefits • To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes • To work in a culture where people thrive because when OUR team thrives, OUR business thrives