Job Closed
This listing is no longer active.
Pharmacy Benefits Investigation - BioPlus Specialty Pharmacy
Location
United States
Posted
93 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Pharmacy Benefits Investigation - BioPlus Specialty Pharmacy
Elevance Health
Anticipated End Date: 2026-03-31 Position Title: Pharmacy Benefits Investigation - BioPlus Specialty Pharmacy Job Description: Pharmacy Customer Associate II LOCATION: This is a virtual eligible role. You must be within a reasonable commuting distance of one of our offices. HOURS: 11:30 am - 8:30 pm, ET, Monday through Friday. TRAINING: 5 Weeks, training will be conducted during regular business hours, 8:00 am - 5:00 pm or 9:00 am - 6:00 pm, ET. Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Pharmacy Techs! The Pharmacy Customer Associate II is responsible for responding to basic customer questions via telephone and written correspondence regarding pharmacy retail and mail order prescriptions. Primary responsibilities include, but are not limited to: - Develops and maintains positive customer relations and coordinates with functions within the company to ensure customer requests are handled and resolved appropriately and in a timely manner. - Interacts with internal and external customers (could include subscribers, providers, group or benefit administrators, physician offices, third party representatives, and other Blue Cross Plans) to provide claims, customer service, and/or membership support. - Completes necessary research to provide proactive, thorough solutions. - Displays ownership of service requests ensuring high quality resolution and follow-thru. - Supports and guides the customer with their personal options and decisions and helps the customer become knowledgeable and confident about using technology, tools and resources available to them. Required Qualifications - Requires a HS diploma or equivalent and previous experience in an automated customer service environment; or any combination of education and experience which would provide an equivalent background. Preferred Qualifications - 2+ years of Specialty Pharmacy experience strongly preferred. - Certified or Registered Pharmacy Technician preferred. - Experience with pharmacy benefits investigation strongly preferred. - Experience processing/interpreting pharmacy claims is very helpful. - Experience with pharmacy prior authorizations and pharmacy billing is very helpful. - Experience working with a variety of therapy types is very helpful. - Strong critical thinking skills are a must for this position. Job Level: Non-Management Non-Exempt Workshift: 1st Shift (United States of America) Job Family: CUS > Care Reps Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.
Job Requirements
- Requires a HS diploma or equivalent and previous experience in an automated customer service environment; or any combination of education and experience which would provide an equivalent background.
- 2+ years of Specialty Pharmacy experience strongly preferred.
- Certified or Registered Pharmacy Technician preferred.
- Experience with pharmacy benefits investigation strongly preferred.
- Experience processing/interpreting pharmacy claims is very helpful.
- Experience with pharmacy prior authorizations and pharmacy billing is very helpful.
- Experience working with a variety of therapy types is very helpful.
- Strong critical thinking skills are a must for this position.
- Location: This is a virtual eligible role. You must be within a reasonable commuting distance of one of our offices.
- Hours: 11:30 am - 8:30 pm, ET, Monday through Friday.
- Training: 5 Weeks, training will be conducted during regular business hours, 8:00 am - 5:00 pm or 9:00 am - 6:00 pm, ET.
- Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs (unless covered by a collective bargaining agreement)
- Medical, dental, vision benefits
- Short and long term disability benefits
- 401(k) + match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
Related Guides
Related Categories
Related Job Pages
More Medical Reviewer Jobs
Associate Manager, Clinical Claim Review- Remote
Gainwell TechnologiesGainwell Technologies is an award-winning digital health technology company that supports the administration of healthcare and human services programs. In past
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for an Associate Manager, Clinical Claim Review who is responsible for supervising the day-to-day prepay, post-pay, prior authorization, and medical record review activities of a multidisciplinary team of Coders, Clinical DRG Auditors, and Nurse Reviewers. Oversees and manages the daily operations of the team by leading, assigning work, ensuring productivity and quality metrics are achieved, and analyzing production and workflow/processes to increase efficiency and quality. Consistently demonstrates effective change management by communicating changes timely and effectively; building commitment and overcoming resistance; supporting those affected by change; monitoring transition and evaluating results. What we’re looking for - Active, unrestricted RN licensure from the United States and in the state of primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required - At least one of the following active Coding Certifications is required and is to be maintained as a condition of employment: RHIA, RHIT, CCS, CIC, CCDS or CPC - 5+ years clinical experience in an inpatient hospital setting required - 3+ years of MS DRG/APR DRG coding or auditing experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies required - Responsible for oversight and hiring of staff, retaining top talent, performance management, coordinating training and education, and providing leadership and mentorship to staff to build and improve skills to provide best-in-class practices to enhance efficiency, quality, and customer satisfaction. - Monitor aging inventory, workload, assignments, productivity, and quality to ensure service level agreements, contract deliverables, and timelines are met. - Evaluate and analyze productivity, utilization, efficiency, finding rates, savings, appeal overturn rate, and reviews completed by staff to identify opportunities for process improvements. - Meet with clients and providers to discuss complex cases, trend analysis, exit and/or settlement conferences. - Serve as a Subject Matter Expert to assess new tools, automation, product development, and clinical readiness; act as a resource for resolving escalated issues, and coach and mentor staff to develop a high-performing team - Analyze reports and data and identify trends and resources that improve the delivery of clinical review services. - Manage and evaluate individual/team performance and take appropriate action to meet and/or exceed performance standards. - Perform other functions as assigned. What we’re looking for - Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) - Bachelor’s degree in business, healthcare administration, or related field preferred - 5+ year’s healthcare experience with increasing responsibility required - 3+ year’s utilization review or health care auditing experience required - 2+ year’s management or supervisory experience preferred - Demonstrates a thorough understanding of clinical criteria and clinical review judgment. What you should expect in this role - Remote (Work from Home) - Up to 20% Travel Applications will be accepted through April 17, 2026. The pay range for this position is $85,000.00 - $110,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
Anticipated End Date: 2026-03-31 Position Title: Medical Management Specialist I Job Description: Medical Management Specialist I Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Medical Management Specialist I will be responsible for providing non-clinical support to the Medical Management and/or Operations areas. How you will make an impact: - Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review). - Provides information regarding network providers or general program information when requested. - May assist with complex cases. - May act as liaison between Medical Management and/or Operations and internal departments. - Maintains and updates tracking databases. - Prepares reports and documents all actions. Minimum Requirements: - Requires a H.S. diploma or equivalent and a minimum of 1 year experience or any combination of education and experience which would provide an equivalent background. Preferred Skills, Capabilities, and Experiences: - Understanding of managed care or Medicaid/Medicare preferred. For candidates working in person or virtually in the below locations, the salary* range for this specific position is $21.74 to $32.59 Location: New York In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Medical Ops & Support (Non-Licensed) Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.
Anticipated End Date: 2026-03-24 Position Title: Medical Management Specialist I Job Description: Medical Management Specialist I Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. The ideal candidate will be located near one of the following Pulsepoints: Norfolk-VA, Richmond-VA, Roanoke-VA, Indianapolis-IN, Atlanta-GA, Tampa-FL, Lake Mary-FL or Miami-FL. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Schedule: This position will work an 8-hour shift from 8:00 am - 5:00 pm, Monday through Friday. Additional hours, including weekends or holidays, may be required based on operational needs. The Medical Management Specialist I is responsible for providing non-clinical support to the Medical Management and/or Operations areas. How you will make an impact: Primary duties may include, but are not limited to: - Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review). - Provides information regarding network providers or general program information when requested. - Regularly interacts with providers regarding authorization related inquiries. - May assist with complex cases. - May act as liaison between Medical Management and/or Operations and internal departments. - Maintains and updates tracking databases. - Prepares reports and documents all actions. - Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information. Minimum Requirements: - Requires a H.S. diploma or equivalent and a minimum of 1 year experience or any combination of education and experience which would provide an equivalent background. Preferred Skills, Capabilities, and Experiences: - Understanding of managed care or Medicaid/Medicare strongly preferred. - Previous experience in healthcare industry and customer service is preferred. - One year of experience working with authorizations is preferred. - Previous experience working with LTSS members or Medicaid is strongly preferred. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Job Level: Non-Management Non-Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Medical Ops & Support (Non-Licensed) Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.
Centessa Pharmaceuticals plc (Nasdaq: CNTA) new kind of pharmaceutical company with a deconstructed R&D environment that prioritizes data driven decision making led by subject matter experts. Centessa is advancing a portfolio of high conviction programs with strong biological validation. Our asset-centric model offers a unique R&D logic that has been applied by single asset companies to improve productivity. This operating model has minimal centralized infrastructure, reduced hierarchy, and exclusive focus on data driven capital allocation. Our teams are uniquely incentivized to expeditiously interrogate key scientific hypotheses. We believe the asset-centric model can lead to improved success rates for programs with greater speed and modest costs. Description of Role We are seeking a Senior Scientist, Drug Safety (Pharmacovigilance) to support pharmacovigilance activities across Centessa’s clinical-stage development programs. Reporting to Centessa’s Head of Safety and Pharmacovigilance, this role will contribute to the review and analysis of safety data to support ongoing safety surveillance, regulatory compliance, and program execution. The Senior Scientist will work closely with cross-functional partners and external vendors to ensure high-quality safety deliverables and maintain inspection-ready pharmacovigilance processes in a fast-paced, development-focused environment. Key Responsibilities - Provide advanced scientific oversight of ICSR and clinical trial SAE evaluation, ensuring medical accuracy, regulatory reportability, and consistency across global development programs. - Lead the development of high-quality case narratives and guide the scientific preparation of regulatory ready case submissions, including SUSARs, in alignment with global reporting requirements. - Drive ongoing safety surveillance activities by analyzing aggregate safety data, identifying emerging safety signals, and contributing to risk–benefit assessments for investigational and marketed products. - Oversee literature surveillance to identify new or evolving safety information, interpret clinical relevance, and communicate findings to cross-functional stakeholders. - Ensure the scientific integrity and quality of safety data through expert review of complex cases and mentorship of junior team members in case assessment and safety data interpretation. - Provide senior level scientific input into the preparation and review of DSURs, line listings, safety summaries, and safety-related sections of protocols, Investigator’s Brochures, and regulatory submissions. - Serve as the lead drug safety representative on cross-functional study teams, shaping safety strategy, influencing program decision-making, and advising on safety issue management. - Maintain expert level knowledge of therapeutic areas and global drug safety regulations, guidelines, and evolving best practices (e.g., FDA, EMA, ICH, CIOMS), and apply this expertise to program decisions and safety governance. - Collaborate with clinical development, clinical operations, regulatory, medical writing, and quality partners to provide scientific leadership on safety topics and ensure alignment on safety strategy and interpretation. - Lead or contribute to complex, cross-functional safety projects, safety signal evaluations, and ad-hoc scientific analyses to support portfolio needs and organizational priorities. Qualifications - PharmD or PhD in scientific field - 6+ years of experience of experience in drug safety in the biotech/pharmaceutical industry with 3+ years of pharmacovigilance compliance experience. - Prior experience facilitating in Safety Risk Assessment Meetings / Safety Review activities required. - Working knowledge of global PV regulations and guidelines applicable to clinical development (e.g., FDA, EMA, ICH, GCP). - Experience with PV databases and safety surveillance tools (e.g., Argus, ArisGlobal, Vault Safety); familiarity with MedDRA coding preferred. - Experience supporting clinical safety case processing and aggregate reporting. - Strong analytical skills, attention to detail, and comfort working across multiple programs. - Clear communicator who works effectively in small, cross-functional teams. - CNS experience preferred. Compensation The annual base salary range for this job level is $145,000 to $190,000. Individual compensation within this range will be determined based on a variety of factors, including qualifications, skills, relevant experience, and job knowledge. In addition to base pay, this role is eligible for a discretionary annual bonus and participation in our equity program, allowing you to share in Centessa’s long-term success. Work Location Remote-based in the US, with <10% travel to headquarters in Boston, MA POSITION: Full-Time, Exempt EEOC Statement: Centessa Pharmaceuticals believes in a diverse environment and is committed to equal employment opportunity for all its employees and qualified applicants. We do not discriminate in recruitment, hiring, training, promotion, or any other employment practices for reasons of race, color, religion, gender, national origin, age, sexual orientation, marital or veteran status, disability, or any other legally protected status. Centessa Pharmaceuticals will make reasonable accommodations for qualified individuals with known disabilities, in accordance with applicable law. Please note: We will not assign referral rights for any unsolicited resumes from recruitment agencies.

