Position Details

Type Not Specified

Experience entry

Exp. Years Not specified

Education Not specified

Category Sales & Business Development

About this role

The Provider Relations Representative supports pharmacy members by answering questions and resolving issues related to contracted PBMs and health plans, claims processing, and reimbursement status. The role uses AlignRx resources to provide prompt, accurate assistance and works closely with PBM Account Executives on PBM and health plan matters.

Key Responsibilities

Serve as the front-line contact for pharmacy member inquiries (calls, emails, faxes)
Resolve claims processing, claims pricing, claims reconciliation, and missing data issues
Maintain knowledge of AlignRx programs and services guides and updates
Conduct data pulls to validate contract information and follow up on eRecon/Central Pay
Document activity in PDMS and review Daily Notes report for follow-up and resolution

Technical Overview

Operational workflow includes performing data pulls to validate contract information, monitoring and resolving eRecon and Central Pay issues, and documenting all activity in the Pharmacy Data Management System (PDMS). The role also reviews the Daily Notes report to ensure issues are followed up and resolved.

Ideal Candidate

The ideal candidate is a customer-focused healthcare operations professional who can resolve pharmacy member questions related to claims processing, reimbursement status, and contracted PBMs/health plans. They are comfortable using operational tools like eRecon and Central Pay, can perform data pulls to validate contracts, and document outcomes in the Pharmacy Data Management System (PDMS). Experience working with PBM account teams is a plus.

Must-Have Skills

serve as front-line contact for pharmacy members (callsemailsfaxes)document call and work activity in the Pharmacy Data Management System (PDMS)follow department workflowpoliciesand proceduresconduct data pulls to validate contract informationfollow up on eRecon and Central Pay issuesmaster knowledge of AlignRx programs and services guides

Nice-to-Have Skills

experience with PBM and health plan issuesexperience working with PBM Account Executive and Senior PBM Account Executive

Tools & Platforms

eReconCentral PayPharmacy Data Management System (PDMS)Daily Notes report

Required Skills

claims processingclaims reconciliationreimbursement statuscontract information validationdata pullseReconCentral PayPharmacy Data Management System (PDMS)Daily Notes report reviewcustomer support email monitoringdirect contractingmissing data handling

Hard Skills

claims processingclaims reconciliationdata pulls to validate contract informationcontract knowledge for AlignRx PSAO contractseRecon issues resolutionCentral Pay issues resolutiondocumentation of call and work activityPharmacy Data Management System (PDMS)Daily Notes report reviewcustomer support email box monitoringfollow defined work planshandling missing dataphoneemailand fax request handling

Soft Skills

customer serviceprompt and accurate issue resolutioncommunicationteam collaborationattention to detailfollow-up and resolution ownership

Industry & Role

Industry Healthcare (Pharmacy Services / PBM Support)

Job Function Provide front-line provider support to pharmacy members for PBM, health plan, and claims operations

Role Subtype Customer Service Rep

Keywords for Your Resume

Provider Relations RepresentativeProvider Relations Reppharmacy membersclaims processingclaims reconciliationreimbursement statuscontract informationAlignRx PSAO contractsPBM account executiveSenior PBM Account ExecutiveeReconCentral Paymissing datadata pullsPharmacy Data Management System (PDMS)Daily Notes reportcustomer support email boxdirect contractingcontracted PBMshealth plansworkflowpoliciesand procedurescallsemailsor faxespharmacy not-contractedAlignRx programs and services guides

Deal Breakers

Must be able to document work activity in the Pharmacy Data Management System (PDMS), Must be able to resolve eRecon and Central Pay issues, Must be willing to follow defined work plans, workflows, policies, and procedures

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