Position Summary:

We are seeking a detail-oriented and analytical Manager, Pharmacy Pricing Appeals to join our Provider Relations team. In this role, you will be responsible for managing and resolving the interaction with the pharmacies related to pricing appeals and claims review requests submitted by the pharmacies or internal teams. This includes performing an initial review of the claim and associated pricing, providing the information to internal teams for review, managing any claim adjustments that may be needed, and communicating any necessary information back to the pharmacies. You will play a critical role in ensuring fair reimbursement practices and maintaining strong relationships with pharmacy partners. 

Position Responsibilities:

• Lead the review and improvement of the pharmacy pricing appeal process in coordination with the Analytics team.
• Lead the review and evaluation of the pricing appeal regulatory requirements with the Legal team.
• Manage intake pharmacy pricing appeals or claims reviews from the pharmacies or internal teams via the applicable intake methods required by internal processes and regulations. This involves managing applicable appeal in-boxes and intake methods.
• Evaluate pharmacy-submitted appeals to ensure they meet established criteria and provide the applicable information to the appropriate internal teams for review.
• Receive the internal claim pricing review and respond to the appealing pharmacy with the information.
• Manage the internal process to update any pricing or make claim adjustments as necessary.
• Collaborate with pharmacies and internal teams to reach equitable reimbursement outcomes.
• Provide appeal response information and feedback to the pharmacies as required.
• Provide clear and timely updates to pharmacies and other stakeholders regarding appeal statuses and outcomes.
• Maintain accurate records of appeals and generate reports on trends and discrepancies.
• Lead the development of and manage the claims review process at the NDC level.
• Support other projects as assigned by the Provider Relations team.
• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance.

Minimum Qualifications:

• Bachelor’s degree required.
• 5+ yrs. of experience in reviewing claims or payment appeals in healthcare, pharmacy, PBM, or other relevant experience. Such prior experience in a pharmacy pricing appeals role includes experience in managing regular correspondence and communication with pharmacies.
• In-depth knowledge of pharmacy operations and drug pricing.
• Familiarity with PBMs and their role in pharmacy reimbursement.
• Strong analytical and problem-solving skills.
• Strong project management skills.
• Excellent communication and interpersonal abilities.
• Experience with and understanding of pharmacy claims processing, pharmacy adjudication systems, and reimbursement workflows.
• Knowledge of state or federal pricing appeal laws.
• Intermediate level of proficiency with Microsoft Excel, Word, PowerPoint.
• Proven track record of working in a fast-paced environment, managing multiple tasks at once and having a go-get attitude to provide persistent outreach to pharmacy providers to close out contracts and tasks.
• Ability to work independently, track work/projects appropriately and remain on task.
• Strong communication skills with the ability to develop effective working relationships with providers and internal and external stakeholders.

Preferred Qualifications:

• Certification in pharmacy technician or related field is a plus.

Location: Denver, CO (Hybrid)

Position Summary:

The IT Help Desk Technician assists in managing our ticketing system, MDM software, and AWS platform while overseeing the onboarding and off boarding IT activities associated with employee profiles.

Position Responsibilities:

• Research end user issues independently, when needed, and document/develop a solution per company standards

• Develop additional MDM automation to facilitate user onboarding

• Identify MDM related company needs and create, configure, test and deploy management of user systems via MDM Software.

• Collaborate with internal partner teams to identify compliance, best practice, or other IT related policy needs within the cross functional existing processes and workflows; identify and present enhancements and deploy solutions to the business.

• Responsible for all onboarding and offboarding related IT activities, including system-wide access, purchasing and retrieving of equipment, upgrades, asset tagging, etc.

• Create Exchange rules to address spam/phishing emails as needed.

• Collaborate with the IT Engineering team to drive systemic improvements to email filtering system.

• Promptly respond to user requests via ticketing system/phone calls/IM

• Assist users with access/system issues

• Write and update documentation for user reference

• Help build and establish procedures for newly established team

• Participate in a Help Desk OnCall schedule (tentatively will be 1 week/month, with potential higher volume at onset as the team grows).

• Responsible for adherence to the Capital Rx Code of Conduct including reporting of noncompliance.

Required Qualifications:

• 2+ Years experience in a Help Desk role (preferably in a medium or larger company)

• A customer-oriented approach to problem resolution

• Experience supporting Mac hardware/OSX in a Help Desk environment

• Experience supporting remote users in a distributed environment

• Experience with Jira Service desk or a similar ticketing system

• Experience with Office 365 suite

• Ability to lift 30 lbs. regularly and up to 50 lbs. occasionally (for NYT “future onsite” roles only)

This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.

Location: Remote (For Non-Local) or Hybrid (Local to Denver or NYC area)

Position Summary:

The Government Programs Operations Specialist is a hands-on position responsible for coordinating the day-to-day operations and activities of the Government Programs Operations team. This position provides the candidate a career growth opportunity while learning about Medicare Part D, Medicaid and Exchange business. 

Position Responsibilities:

• Manage the Government Programs Operations team shared Outlook mailbox, including but not limited to timely, accurate and complete responses, and ensuring timeframes for deliverables.
• Lead and execute pharmacy outreach initiatives related to CMS disputes, ensuring compliance with regulatory requirements and internal Government Operations procedures while applying judgment in communication strategy and issue resolution
• Serve as a key contributor in the validation of system enhancements, including evaluating output data, identifying discrepancies, and providing recommendations to improve system performance and data integrity. 
• Design, maintain, and continuously improve structured documentation frameworks, including job aids, policies and procedures (P&Ps), standard operating procedures (SOPs), and training materials to support operational consistency and scalability. 
• Develop and optimize internal workflows and job aids, driving process standardization and identifying efficiency opportunities across Government Programs Operations. 
• Oversee daily PDE reconciliation activities, analyzing trends, identifying variances, and proactively addressing discrepancies to ensure data accuracy and compliance. 
• Manage and resolve escalations arising from claims monitoring activities by applying critical thinking, root cause analysis, and cross-functional collaboration. 
• Support strategic Government Programs Operations initiatives, contributing insights, process improvements, and subject matter expertise as assigned. 
• Plan, coordinate, and facilitate cross-functional meetings to drive alignment, resolve issues, and advance operational objectives. 
• Collaborate closely with Government Programs Operations team members and business partners to address operational needs, improve processes, and support broader organizational goals. 

Required Qualifications: 

• 3+ years of experience in an equivalent role 
• High school diploma required 
• Experience with Medicare Part D and/or Pharmacy Technician experience preferred 
• Organizational skills and a very keen eye for detail and accuracy. 
• Experience working in high-growth, startup environments - an advantage. 
• A positive and upbeat attitude, and excellent interpersonal communication skills.
• A commitment to delivering a high level of customer service, both internally and externally. 
• Flexibility to respond to a range of different work situations. 
• An ability to work under pressure and juggle multiple priorities at any given time. 
• An ability to work well independently and be an effective collaborator within and across teams. 

1. Serve as the lead technician by acting as a role model and training in the Pharmacy Technician processes.
2. Enter patient information and prescription orders in the computer.
3. Interact with third-party prescription plans to solve adjudication problems in order to facilitate the processing of prescriptions.
4. Profile and aid in the dispensing of prescription orders under the supervision of a pharmacist. This may include training in prescription compounding of specialty medications.
5. Manage cash register transactions in a courteous manner to help complete the patient experience in a positive way.
6. Complete daily cash and checks reconciliation and daily sales sheet, and give to the finance department for posting to monthly revenue.
7. Manage and order OTC inventory in addition to assisting with RX inventory management in order to meet budgetary goals. Train others in this process and ensure its completion.
8. Deliver excellent customer service by utilizing Relationship-Based Care to advocate for safety, patient preferences, and optimal communication through partnering with patients and families.
9. Role model the principals of a Just Culture.
10. Perform other duties as assigned. Must be HIPAA compliant.

• Experience in the healthcare industry is preferred.

• N/A

• State of Colorado Pharmacy Technician Provisional Certification (PHATP) required

• Must be adept at typing and using various computer programs. Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.

• N/A

PRN (POOL) benefits include: Wellbeing reimbursement funds and 403(b) contribution eligibility 

•    Interprets physician prescription orders for medications and evaluates for dosage, route, frequency, interaction and demonstrates the knowledge and skills necessary to provide care based upon physical, motor/sensory, psychosocial and safety appropriate to the age of the patient.  Counsels the patient about the medication prescribed with the appropriate medication information.
•    Helps to manage prescription inventory by ordering and maintaining appropriate par levels. Reconciles order invoices to the computer inventory.
•    Supervises and coordinates the pharmacy technician's activities and duties.
•    Compounds and dispenses pharmaceuticals according to the prescription of the LIP guaranteeing safety and accuracy.
•    Actively participates as a collaborative member of the healthcare team by communicating constructively, identifying clinical and interdepartmental areas for improvement by the involved departments.
•    Supervises all aspects of the compounding of specialty meds.

•    Experience in the healthcare industry is required.
•    Previous experience with a changing work load, schedule, and priorities is preferred.

•    State of Colorado Pharmacist license required
•    Basic Life Support (BLS) required
•    Pharmacy-Based Immunization Delivery Certificate or Adult Immunization Training Program for Pharmacists Certificate preferred.

• N/A

Benefits at Vail Health Include:

• Competitive Wages & Family Benefits:
  • Competitive wages
  • Parental leave (4 weeks paid)
  • Housing programs
  • Childcare reimbursement 
• Comprehensive Health Benefits: 
  • Medical
  • Dental 
  • Vision
• Educational Programs: 
  • Tuition Assistance 
  • Existing Student Loan Repayment
  • Specialty Certification Reimbursement
  • Annual Supplemental Educational Funds
• Paid Time Off:
  • Up to five weeks in your first year of employment and continues to grow each year.
• Retirement & Supplemental Insurance:
  • 403(b) Retirement plan with immediate matching 
  • Life insurance
  • Short and long-term disability
• Recreation Benefits, Wellness & More:
  • Up to $1,000 annual wellbeing reimbursement
  • Recreation discounts
  • Pet insurance