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The Client Operations Admin provides administrative support for client pharmacy benefit accounts, handling the documentation, data entry, correspondence, and coordination tasks that keep accounts running smoothly. This role manages member and provider communications, processes prior authorization (PA) paperwork, prepares implementation and configuration documents, maintains client records and reporting, and investigates claims and eligibility discrepancies. The ideal candidate is detail-oriented, highly organized, and comfortable managing multiple administrative queues and deadlines.
Role and Responsibilities
Communications and Member Support
Manage texts, service emails, incoming calls, and voicemail
Serve as an escalation point for issues from the Helpdesk agents, resolving calls and questions they cannot handle or view in the PBM system
Maintain and update the Helpdesk instructions/protocols
Respond to prior authorization status inquiries from providers and partner vendors
Resolve member inquiries such as coverage/cost questions, requests for cards, and prior authorization clinical criteria
Print and mail prior authorization denial letters to members
Assist members with member portal registration and viewing claims for dependents
Enter rejection overrides when appropriate and call pharmacies to assist with claim adjudication
Clinical Support
Assist with the daily rejection report and initiating prior authorization faxes
Manage the prior authorization ticket queue: review and triage incoming tickets, remove duplicates, and archive inactive or aged tickets
Update provider fax information and resend prior authorization forms or decision faxes
Reach out to providers for missing clinical information
Implementation and Configuration Support
Coordinate data collection for new accounts and renewals
Cross-reference current plan design and “free meds” list against standard programming and confirm the plan for the new benefit year
Draft the implementation form and submit it for programming
Create Plan Change request forms for client/agent signature and submit plan changes to programmers
Draft legal documents (data entry on existing templates)
Create account structures for programmers and submit account structure changes to as needed
Create drug/product lists with GPIs when clients request custom programming
Convert past claim files into proper format for bulk override entries
Review sample member cards for accuracy before they are sent to the printer
For renewals with a TPA change, map old cardholder numbers to the new ones so current deductible and out of pocket values can be loaded
Run claims testing to validate configuration accuracy
Assist with the integration process for vendors such as analytics, stop loss, or internal health clinics
Building Client Relationships
Attend weekly client meetings and track progress of open issues
Maintain records of people with reporting portal, PBM portal, and member portal access and submit new access requests/changes to appropriate team
Conduct brief tutorials of the various portals
Assist with questions regarding specific reports and resolve discrepancies
Assist when issues arise in claims adjudication
Submit requests to appropriate team for automated invoice subscriptions and report delivery
Maintain records of invoice, report, and rebate recipients, and submit change requests as necessary
Work with Marketing team to create new client-facing lists and collateral upon request (e.g., expanded PA lists, GLP-1 clinical criteria outlines)
Submit clinical criteria for client approval when changes are made or medications are added
Provide census files and member contact information to partners/vendors
Convert TPA files into usable formats for partners/vendors (e.g., high-cost medication member lists for outreach)
Convert census files into formats…