Positive Overview

At Zelis, the High Cost Drug Product Specialist role is responsible for driving incremental savings solutions for our clients in the high-cost drug space across payment integrity. They will be responsible for developing a continual flow of new high-cost drug concepts and driving innovation around enhanced claim selections. This position will not only drive new concept creation, but also focus on the delivery and execution of these concepts across payment integrity. This individual will work closely and collaborate with leaders across Expert Claim Review, Claims Editing, and the Office of the Chief Medical Officer.

Key Responsibilities

• Review payer policies and summary plan descriptions for high-cost drug concept creation and applicability relative to Zelis clients

• Responsible for new concept creation and innovation of high-cost drug savings opportunities for both Claim Editing and Expert Claim Review products

• Ensures the deployment and execution of new concepts across payment integrity

• Accountable for the oversight of claim selection and oversee medical drug claim flow

• Serve as subject matter expert for Payment Integrity including troubleshooting and review for data accuracy

• Serve as a subject matter expert for high-cost drug reviews and provide support where needed for inquiries and provider disputes of high-cost drug claims

• Create and present education specific to high-cost drug to payment integrity teams as well as various other departments

• Research and analysis of content for high-cost drug reviews

• Use of strong industry knowledge to create and maintain high-cost drug review content, including but not limited to review rationales, policies, review guidelines and templates, and dispute rationales

• Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional opportunities

• Support for client facing teams as needed relating to client inquiries

• Communicate and partner with CMO and members of Payment Integrity leadership team regarding important issues and trends

• Ensure adherence to quality assurance guidelines

• Monitor, research, and summarize trends, coding practices, and regulatory changes

• Actively contribute new ideas and support ad hoc projects, including time-sensitive requests

Professional Experience

• Bachelor’s Degree in business, healthcare, or technology

• Doctor of Pharmacy preferred

• Current pharmacist licensure with at least 10 years of pharmacy experience

• Strong knowledge of pharmacology, high-cost medications, and specialty drug therapies

• Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner

• Background and/or understanding of the healthcare industry

• Knowledge of National Medicare and Medicaid regulations

• Knowledge of payer reimbursement policies

As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We’re Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.

Commitment to Diversity, Equity, Inclusion, and Belonging
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.

Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

We encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.

Accessibility Support

We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com

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