Lead Pharmacy Systems Operations Specialist

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October 30

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GoodRx

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Healthcare Insurance • Pharmaceuticals • B2C

GoodRx is a company that helps consumers in the United States save money on their prescription medications. They provide a platform that allows users to compare drug prices and find the lowest costs at pharmacies in their area. GoodRx aims to make prescription medications more affordable for individuals by offering discounts and coupons.

501 - 1000 employees

Founded 2011

⚕️ Healthcare Insurance

💊 Pharmaceuticals

👥 B2C

💰 $100M Private Equity Round on 2020-09

📋 Description

• Manage pharmacy system adjudication of GoodRx and Scriptcycle Retailer Programs on the pharmacy claims adjudication platform. • Monitor and analyze inbound and outbound claims to ensure accurate adjudication according to program design and pricing requirements. • Research, resolve, and document claim errors, rejects, and discrepancies within established service-level agreements (SLAs). • Collaborate with PBM partners and pharmacies to address claim inquiries and resolve escalations efficiently. • Develop, implement, and maintain standard operating procedures (SOPs) for adjudication processes. • Track and report operational metrics, trends, and recurring issues to management, recommending process improvements. • Support the development and implementation of quality assurance (QA) metrics for claims processing. • Ensure compliance with CMS, HIPAA, and other regulatory guidelines in all claims adjudication activities. • Perform audits to confirm accuracy of pricing and business rules. • Act as a liaison between internal stakeholders and external partners to resolve claims-related issues. • Provide training and guidance to internal teams on adjudication processes, workflows, and system capabilities.

🎯 Requirements

• 8+ years with a bachelor’s degree or equivalent, or equivalent practical experience as project or implementation manager, within pharmacy sector • Understanding of pharmacy claim adjudication, application of pricing rules, and associated claim data • Proficiency in pharmacy claims systems, EDI transactions (NCPDP D.0 / F6, 835), and benefit design configuration. • Proven track record of juggling multiple projects at a time while maintaining strong attention to detail • Analytical problem solver with a strong work ethic who can work independently and collaboratively • Strong SQL and Excel proficiency, or other data analysis/reporting tools preferred. • Experience working with Power BI or Looker (preferred)

🏖️ Benefits

• medical, dental, and vision insurance • 401(k) with a company match • an ESPP • unlimited vacation • 13 paid holidays • 72 hours of sick leave • mental wellness and financial wellness programs • fertility benefits • generous parental leave • pet insurance • supplemental life insurance for you and your dependents • company-paid short-term and long-term disability