Director of Pharmacy Claims & Reimbursement

Description

At Clarest Health, we are a leading healthcare organization committed to transforming patient care through innovative pharmacy services and personalized medication management. Our mission is to deliver high-quality, patient-centered care by leveraging technology, industry expertise, and medication data analytics to improve clinical outcomes, streamline medication management, and drive cost-effective solutions. We partner with healthcare providers and home-based caregivers to ensure the best care for every patient, enhancing patient health at every step. Our automated dispensing solutions and efficient pharmacy services improve the overall efficiency of healthcare operations while ensuring the highest standards of patient care. As a part of the Clarest Health team, you'll contribute to a mission-driven organization that is redefining the future of pharmacy services and making a meaningful impact on the lives of patients and healthcare professionals across the nation. Join us in our commitment to excellence, innovation, and improving healthcare outcomes for all.

About the role

This is a unique opportunity for a licensed pharmacist leader to drive operational excellence, improve reimbursement outcomes, influence enterprise-wide strategy, and help shape the future of pharmacy services in a growing healthcare organization committed to delivering exceptional care and customer service.

Responsibilities

• Leads all third-party claims adjudication and clinical rejection management activities, including formulary alternative recommendations, prior authorization review, and resolution of complex coverage issues.
• Provides leadership, direction, and workforce planning for Claims Adjudication and Clinical Service Center teams, including pharmacists and pharmacy technicians.
• Ensures the Adjudication team, CSC Pharmacists, and CSC Technicians are provided with instructions regarding actions to be taken when working with insurance plans and internal/external customers, to take steps toward rejected claims resolution.
• Establishes and maintains effective relationships with internal/external customers in order to gain their trust and respect as well as to identify and implement improvements in departmental/pharmacy products and services.
• Partners with Billing, Account Management, and Operations leadership to drive pharmacy performance, service excellence, and customer satisfaction outcomes.
• Collaborates with customers, insurance companies, and internal pharmacy staff to effectively and appropriately resolve rejected clinical claims.
• Ensures organized record keeping of all CSC documentation related to Agent Agreements and claims management.
• Provides direction and guidance on the development, deployment, and management of department and customer supported initiatives.
• Enforces all company and departmental policies and procedures.
• Ensures compliance with all applicable state and federal regulations related to departmental pharmacy practices.
• Identifies and champions automation and technology solutions that improve claims resolution efficiency, accuracy, and scalability.
• Develops and maintains Medicare Part D customer collateral, ensuring materials are accurate, current, and reflective of annual plan changes.
• Oversees facility-level Medicare Part D reporting, providing customers with timely and accurate information to support their residents’ pharmacy benefit needs.
• Oversees the Medicare Part D customer inquiry function, providing guidance and supervision to the staff member responsible for managing the departmental inbox and ensuring questions are fielded and resolved accurately and promptly.
• Leads the assisted living cost request process for current and prospective pharmacy customers, ensuring accurate, timely, and competitive pricing support.
• Oversees the patient intake function for the Clarest at Home pharmacy program, including the creation and maintenance of patient profiles within the pharmacy operating system.
• Responsible for the resolution of all rejected insurance claims within the Clarest at Home pharmacy program, ensuring timely and accurate adjudication.
• Oversees billing functions for the Clarest at Home program, ensuring accuracy and compliance with applicable payer and regulatory requirements.
• Develops and implements all processes and procedures related to patient intake, adjudication, and billing, and supervises staff responsible for the day-to-day execution of these functions.
• Maintains the Adjudication & CSC operating budget to achieve budget expectations.
• Reviews weekly/monthly subscription reports from Veridikal for revenue optimization, compliance, trends and takes appropriate actions.
• Establishes, monitors, and reports on key performance indicators related to claims resolution, turnaround times, productivity, customer service, and departmental quality outcomes.
• Investigate and implement new software and tools for the CSC group.
• Maintains payroll for exempt and non-exempt employees including time off requests.
• Reviews, prepares, and presents Quarterly Business Review (QBR) data to external stakeholders, ensuring insights are accurate, professionally communicated, and aligned with organizational goals.

Qualifications

• Degree in Pharmacy is required, PharmD preferred.
• Licensed in practicing state required.
• Licensure in additional states may be required as necessary based on future activity/requirements of the department.
• Experience in pharmacy or healthcare environment as licensed pharmacist.
• Pharmacy management with prior adjudication or claims processing experience, formulary / clinical expertise preferred, especially related to Medicare Part D.
• Experience in insurance claims adjudication, retail pharmacy, and program development preferred.
• Strong computer knowledge and skills in report development using MS Word, Excel, and PowerPoint required.
• Experience with Cover My Meds and workflows.

Skills & Abilities

• Pharmacy Claims Adjudication & Reimbursement Expertise – Extensive knowledge of pharmacy claims processing, Medicare Part D, prior authorizations, formulary management, and complex claim resolution strategies.
• Leadership & Team Development – Proven ability to lead, coach, and develop high-performing teams while fostering accountability, engagement, and operational excellence.
• Clinical Decision-Making – Strong clinical pharmacy knowledge with the ability to evaluate therapeutic alternatives, interpret payer requirements, and support appropriate medication utilization.
• Operational & Process Improvement – Demonstrated success optimizing workflows, implementing process improvements, and identifying automation opportunities that enhance efficiency, quality, and scalability.
• Data Analysis & Performance Management – Ability to leverage operational and financial data, develop key performance metrics, identify trends, and drive continuous improvement initiatives.
• Cross-Functional Collaboration & Customer Focus – Strong relationship-building and communication skills with the ability to effectively partner with Operations, Billing, Account Management, Clinical Services, customers, and external stakeholders to achieve business objectives.

Benefits

We offer comprehensive medical, dental, and vision insurance, paid time off, free virtual care & telemedicine, OneVillage Wellness Support, a 401(k) with company match, referral bonuses, life insurance, and more. We are committed to making a difference in the lives of others!

Pay

$185 - $190k + bonus

Schedule

This is a remote position; however, candidates must reside within reasonable proximity to our Clinical Innovation Center in Arizona (4645 E Cotton Center Blvd, Ste 100, Phoenix, AZ 85040). Periodic on-site attendance will be required for meetings, collaboration, training, and other business needs.

Equal Opportunity Employer

Clarest Health is an Equal Opportunity Employer. Reasonable accommodations will be made to enable individuals with disabilities to apply for a job or to perform the essential functions of their job.