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: 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. 

Position Summary:

Responsible for taking incoming requests for first, second level and external appeals while ensuring high level of customer service and maximizing productivity. Work with appeals team for multiple lines of business such as Commercial, Exchange and Medicare, ensuring the proper submission of appeals for review by pharmacist and medical directors.

Position Responsibilities:

• Maintain quality and productivity standards for all cases reviewed while meeting established turnaround time requirements.
• Remain current on all communications and updated processes relayed through multiple communication channels and apply to daily responsibilities.
• Follow all internal Standard Operating Procedures and adhere to HIPAA guidelines and policies.
• Review all cases received, to verify if case meets qualifications for appeal review.
• Performs triple check to ensure quality reviews and handling in accordance with policies and procedures.
• Updates case types, sends appeal acknowledgements, and submits case information to independent review organizations.
• Communicate effectively with appeal pharmacists regarding internal and external appeals.
• Make verbal outreach attempts to obtain necessary information for case review and record accurate information obtained on the call.
• Exhibit excellent phone and communication skills while providing complete and accurate information to members and providers.
• Performs all other related duties as assigned

Minimum Qualifications:

• 1 + years’ experience working as a certified pharmacy technician in a managed care or PBM setting required.
• Active, unrestricted certified pharmacist technician license required.
• Excellent organization details and strong detail orientation.
• Strong oral and written communication skills.
• Ability to work independently with minimal supervision, stay productive in a remote, high-volume, metric driven environment with shifting priorities.
• Ability to work 12pm-9pm EST hours

Preferred Qualifications:

• Experience working with commercial and medicare appeals preferred

Nothing in this position description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

Remote, US Salary Range
$60,000.00 - $65,000.00  USD
New York, NY Salary Range
$78,800.00 - $98,500.00 USD
Denver, CO Salary Range
$72,000.00 - $90,000.00 USD

About Capital Rx

Capital Rx is a full-service pharmacy benefit manager (PBM) and pharmacy benefit administrator (PBA), advancing our nation’s electronic healthcare infrastructure to improve drug price visibility and patient outcomes. As a Certified B Corp™, Capital Rx is executing its mission through the deployment of JUDI®, the company’s cloud-native enterprise health platform, and a Single-Ledger Model™, which increases visibility and reduces variability in drug prices. JUDI connects every aspect of the pharmacy ecosystem in one efficient, scalable platform, servicing millions of members for Medicare, Medicaid, and commercial plans. Together with its clients, Capital Rx is reimagining the administration of pharmacy benefits and rebuilding trust in healthcare.

Capital Rx values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Position Summary: 

The Provider Relations Specialist provides essential credentialing review and management to support the Capital Rx networks of pharmacies. This work involves deciding whether pharmacies meeting Capital Rx’s credentialing requirements allowing for inclusion in the Capital Rx pharmacy networks and maintaining the information related to credentialing. The ideal candidate will have experience in credentialing providers, managing reporting requests, and contribute to scalable solutions to streamline processes.  

Position Responsibilities: 

• Manage the standard credentialing review process for applicable pharmacies for inclusion in the provider networks and maintain the information related to credentialing so that Capital Rx has the most relevant information available. This includes getting applicable licenses and certificates of insurance from pharmacies as well as verifying eligibility in the NCPDP database and federal and state websites (e.g. OIG, GSA, SAM) and using that information to decide whether the pharmacy meets the credentialing requirements for Capital Rx.  

• Manage, review and decide whether the applicable pharmacies are valid by reviewing exclusion lists on an ongoing basis to identify any excluded pharmacies and referring those pharmacies to the appropriate team members/departments for removal. 

• Manage the development and maintenance of a credentialing database to ensure proper tracking of all relevant credentialing information. 

• Manage credentialing reporting requests. 

• Gather and track annual pharmacy required attestations. 

• Manage and review development and implement of credentialing policies and procedures. 

• Gather pertinent information from pharmacies regarding services offered and opportunities and provide direct contracting support to Provider Relations leadership as needed. 
• Provide other assistance as assigned to the Provider Relations team. 

Required Qualifications: 

• 2+ yrs. of experience in healthcare, pharmacy credentialing, contracting, provider relations, pharmacy, account management or other relevant experience. 

• 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. 
• Intermediate level of proficiency with Microsoft Excel, Word, PowerPoint. 

Preferred Qualifications: 

• PBM and pharmacy technician experience preferred 

• Bachelor’s degree preferred 

Location: Hybrid (Local to NYC)

Position Summary: 

The Provider Relations Specialist provides essential credentialing review and management to support the Capital Rx networks of pharmacies. This work involves deciding whether pharmacies meeting Capital Rx’s credentialing requirements allowing for inclusion in the Capital Rx pharmacy networks and maintaining the information related to credentialing. The ideal candidate will have experience in credentialing providers, managing reporting requests, and contribute to scalable solutions to streamline processes.  

Position Responsibilities: 

• Manage the standard credentialing review process for applicable pharmacies for inclusion in the provider networks and maintain the information related to credentialing so that Capital Rx has the most relevant information available. This includes getting applicable licenses and certificates of insurance from pharmacies as well as verifying eligibility in the NCPDP database and federal and state websites (e.g. OIG, GSA, SAM) and using that information to decide whether the pharmacy meets the credentialing requirements for Capital Rx.  

• Manage, review and decide whether the applicable pharmacies are valid by reviewing exclusion lists on an ongoing basis to identify any excluded pharmacies and referring those pharmacies to the appropriate team members/departments for removal. 

• Manage the development and maintenance of a credentialing database to ensure proper tracking of all relevant credentialing information. 

• Manage credentialing reporting requests. 

• Gather and track annual pharmacy required attestations. 

• Manage and review development and implement of credentialing policies and procedures. 

• Gather pertinent information from pharmacies regarding services offered and opportunities and provide direct contracting support to Provider Relations leadership as needed. 
• Provide other assistance as assigned to the Provider Relations team. 

Required Qualifications: 

• 2+ yrs. of experience in healthcare, pharmacy credentialing, contracting, provider relations, pharmacy, account management or other relevant experience. 

• 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. 
• Intermediate level of proficiency with Microsoft Excel, Word, PowerPoint. 

Preferred Qualifications: 

• PBM and pharmacy technician experience preferred 

• Bachelor’s degree preferred 

The Company is seeking a highly motivated, self-starter who is looking for a challenging career with a fast-growing company in the specialty pharmacy management services.  Critical to this position is a person who is able to work independently and establish strong and credible relationships with patients, clinicians and internal Shields staff.  Applicants should be results-oriented with a positive outlook, and a clear focus on high patient quality and service. Detail orientation and strong administrative/organization skills are required. Mature, approachable, professional and comfortable in dealing with others both in-person and on the phone.  Applicant must be reliable, tolerant, and determined; an empathetic communicator, able to see things from the other person's point of view.  Most importantly, person must be able to work as a member of a close-knit team.

You'll spend much of your day working across multiple software platforms at once, so being tech-savvy is essential. While we will provide ample training, this role requires candidates to come to the table with a strong technical foundation, including the ability to work seamlessly across multiple software applications simultaneously.  If you're the type who can juggle several browser tabs, toggle between applications without missing a beat, and pick up new software quickly, you'll thrive in this role!

Provides integrated support to patients and pharmacists by providing a 'hands-on" approach to total quality patient care. Works closely with patients to deliver a full continuum of medication adherence support by utilizing our various tools and applications. Encourages patients of specialty clinics to utilize pharmacy to fully benefit from its superior patient care services. Given that the Pharmacy Liaison will be located in one of the medical center clinics, seamlessly integrating with the clinic team (doctors, nurses, staff, etc.) is critical to the liaison's success.

Job Duties:

• Provide "legendary" care to hospital patients by providing a full suite of custom medication management services
• As a member of the clinic team, work seamlessly alongside hospital clinicians to serve patients both face-to-face and over the phone
• Educate prospective pharmacy patients on how hospital serves patients and improves their overall care;
• Support outpatient retail and specialty prescription medication needs;
• Grow the specialty pharmacies patient population
• Ensure that patients remain on track with medication regimens- outbound therapy/medication adherence check-ups; secures refill prescriptions, etc;
• Communicate effectively with the centralized Patient Service Center with respect to such communications as: the refill report, the zero-fill report, the monthly outstanding report and the appointment list;
• Help develop new processes to ensure smooth operations and patient care;
• Identify medications requiring special storage and/or handling such as hazardous medications and/or refrigerated medication;
• Identify supplies necessary for select medications such sharps containers, needles/syringes, alcohol swabs, Band-Aids;
• Answer, resolve and triage inbound inquiries;
• Perform refill reminder calls under the supervision of a pharmacist;
• Resolve insurance related issues, including prior authorizations (PAs), and assist patients with various forms of financial assistance;
• Ensure appropriate documentation in all required systems/tracking mechanisms;
• Manage, organize, and update relevant data using database applications;
• Apply observations and recommendations to operational issues, increased productivity, quality, and customer-service standards;
• Identify trends, resolves problems; recommend improvements; implement change;
• Actively participate in process improvement initiatives;
• Act as a value-added business partner to stakeholders throughout the organization;
• Protect organization's value by keeping information confidential;
• Update knowledge by participating in educational opportunities; reading professional publications; maintaining networks; participating in professional organizations;
• Willing to do whatever is necessary for the betterment of the Company;
• Other duties as assigned;

Experience/ Education:

Required Licensure/Certification:  We are seeking experienced pharmacy technicians. Nationally certified as a CPhT is preferred but not required

Years of Experience: Required 2 years, Preferred 3-5 years experience as a Pharmacy Technician

Education: High School Diploma or GED required

Skills: The ability to communicate fluently in Spanish is a must for this role.

Strong interpersonal communication skills, ability to work independently and demonstrate good judgement, strong verbal and written communication, highly proficient in Microsoft Office particularly Excel and Word; able to quickly learn other software programs and able to extract relevant information; strong organizational/administrative skills a must 

Traits: Organized, high-integrity, attention to detail, dependable, quality focus, empathetic, good listener/communicator

Other:  Energetic, highly motivated, team player with strong personal and communication skills; discretion and confidentiality essential as position deals with highly sensitive and private data

Specialties: Knowledge of transplant, hepatitis C, infectious disease (including HIV), and/or oncology a plus

This information is being provided to promote pay transparency and equal employment opportunities at Shields Health Solutions. An employee in this position can expect a salary rate between $66,300.00 and $70,000.00 plus bonus pursuant to the terms of any bonus plan if applicable. The actual salary will depend on experience, seniority, geographic location, and other factors permitted by law.

Manager Patient Services

The Company is seeking someone with strong people management skills highly motivated, self-starter who is looking for a challenging career with a fast-growing company in the specialty pharmacy management services. This applicant should be results-oriented with a positive outlook, and a clear focus on high quality. A natural forward planner who critically assesses their own performance. The ideal candidate should have front-line employee management experience with a background in pharmacy or healthcare.  Applicant should be service-oriented with a motivational style incorporating a clear focus on performance accountability and employee development. The applicant must be able to work as a member of a close-knit team.

The Manager of Patient Services is a key front-line manager supporting the Shields Health Solutions specialty pharmacy and medication adherence model.  The manager provides day-to-day management for a team of pharmacy liaisons located in specialty clinics within hospital settings.  The manager is responsible for ensuring the adoption and continuity of best practices, providing ongoing support, coordinating coverage, coaching, performance management and professional development of the Specialty Liaisons

Key Responsibilities

• Leads assigned Specialty Liaison team, managing and directing activities essential to providing the highest quality experience for patients in specialty clinics
• Coach and develop liaison team and instill Shields culture at health system partner site
• Provide consistent, timely and ongoing performance coaching, feedback, training, and development to liaison teams
• Facilitate effective communication between liaison, Shields functional group, pharmacy, and clinic teams
• Meet or exceed site operational targets surrounding clinic service, growth, and patient satisfaction & outcomes
• Proactively identify and implement improvement initiatives at health system partners to drive growth and efficiency
• Engage with Shields functional group leadership to ensure operational targets are met and drive growth and efficiency
• Establish credible relationships with stakeholders at health system partners including clinic leadership and pharmacy teams up to Manager and Director levels
• Ensure a high level of partner satisfaction by proactively communicating the value of Shields’ clinic operations team, addressing concerns responsively, and providing regular updates to clinic leadership
• Collaborate with regional leadership teams to implement strategic growth initiatives including new clinic launches, workflow changes, and other growth initiatives
• Provide performance updates to Shields leadership team
• Ensures Specialty Liaison team accountability and the consistent use of best practices for execution of the following critical responsibilities: prior authorizations, patient financial assistance, medication refills, patient appointments, and patient outreach
• Ensures coverage for Specialty Liaisons when absent from work
• Effective problem-solver who works through barriers for success within clinics and with the support staff within the home office
• Identifies issues within a clinic and works with their manager to create tangible action plans to improve performance and ensures timely implementation of improvement efforts
• Collaboratively partners with the data analytics team and Patient Support Center to execute on identified opportunities
• Identifies, assesses and contributes to continuous process improvement and optimization initiatives
• Provides subject matter expertise to hospitals and clinics within their span of control
• Other duties as assigned

Education & Experience

• Bachelor's degree or equivalent work experience required with a minimum of 2 years supervisory/management experience preferred
• 5 years working in a healthcare or pharmacy environment with direct patient and clinician contact required
• National Certification as a CPhT (or equivalent) and prior experience as a licensed pharmacy technician would be optimal in this role
• Experience working within a retail, hospital or provider type setting communicating with physicians, nurses, and other healthcare professionals (preferably in an outpatient or medical clinic setting) is a plus.
• Strong communication skills, highly proficient in Microsoft Office particularly Excel and Word
• This candidate will be able to quickly learn other programs and extract relevant information
• Possess strong organizational skills is a must
• Ability to manage the performance of individuals against quantitative metrics without compromising clinical quality
• Patient-centered, organized, high-integrity, motivational, attention to detail, dependable, quality focus, empathetic, good listener/communicator, a good teacher, able to lead a group of individuals
• Energetic, highly motivated, team player with excellent attention to detail; discretion and confidentiality essential as position deals with highly sensitive and private health information
• Has the ability to effectively train employees, lead by example and use motivational techniques to improve/maintain employee engagement
• Motivates and inspires
• Results orientation
• Relationship builder
• Collaborative, team player
• A passion to help people
• Drive to succeed
• Confidential

Job Salary: 

An employee in this position can expect a salary rate between $80,000 and $95,000 plus bonus pursuant to the terms of any bonus plan if applicable. The actual salary will depend on experience, seniority, geographic location, and other factors permitted by law.