Sr Specialist, Pharmacy Claims

Sr. Specialist, Pharmacy Claims

Location:

Lincoln, Nebraska

Join a Mission-Driven Organization We're seeking a problem-solver who enjoys tackling complex challenges, investigating and resolving pharmacy claim issues, and delivering exceptional service to our members. Join our Medical Claims team in Lincoln, NE, and make a meaningful impact by helping ensure accurate and timely claims resolution We’re proud to be named one of Lincoln’s Best Places to Work—and we’re looking for people who care deeply about helping others and want to grow with a mission-driven organization.

NRECA is the national trade association representing more than 900 consumer-owned electric cooperatives across the United States. We provide advocacy, financial services, and business solutions that help over 900 consumer-owned electric cooperatives across the country serve their communities and we operate with integrity, transparency, and a spirit of innovation. The work in the Insurance & Financial Services department (I&FS) is dynamic and intellectually challenging, engaging, and deeply impactful.

They work to develop and administer employee benefit plans and services which are diverse and the results help improve the quality of life for hard working Americans across the country. They foster a culture that emphasizes a strong sense of diversity, integrity, and belonging, driven by NRECA’s core values like communication, creative problem-solving, collaboration and accountability. If you’re motivated by purpose, enjoy variety, and care about people and outcomes, this is the team for you.

As a Sr. Specialist, Pharmacy Claims, you'll resolve pharmacy claim issues, be the go-to expert for pharmacy benefit questions and escalation, and identify opportunities to improve processes, systems, and service delivery. The work schedule is 8:15 a.m. to 5:00 p.m. and the position is eligible for NRECA’s hybrid schedule which allows flexibility to work from home up to 2 days per/week.

• Troubleshoot pharmacy claim issues
• Answer questions from members and providers.
• Work with internal and external partners to resolve complex benefit concerns.
• Balance investigative work with customer service while also looking for opportunities to improve processes and prevent future issues.

Required Education and

Certifications:

Associate’s degree in a related field (health administration, pharmacy technician, desired), or combination of education and experience;
Certification in a medical terminology course or coursework in medical anatomy.

Preferred Education:

Insurance coursework such as LOMA, AHIP, ICA or CEBS, desired.

Required Experience:

7 or more years of experience with prescription claims processing for commercial insurance carriers. 5 years of experience working in a pharmacy; or 5 years’ experience with a PBM in a group insurance setting.

• Knowledge of pharmacy benefit management (PBM), including benefit design, coverage limitations, and formulary processes.
• Understanding of applicable regulations, including HIPAA, ACA, Medicare Part D, and other federal mandates.
• Knowledge of pharmacy and health claims operations, compliance requirements, and contractual plan language, with the ability to interpret and apply medical, technical, and contractual information to claims.
• Strong analytical and critical thinking skills, with the ability to identify issues, evaluate information, and draw sound conclusions.
• Excellent interpersonal and customer service skills.
• Effective verbal and written communication skills, with the ability to interact professionally with members, employees, and vendors.
• Ability to exercise sound judgment, discretion, and…