Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Manager & Professional
2017E Requisition #
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To coordinate and manage the pharmacy plan/ benefit design implementation process in partnership with Health Plan’s pharmacy benefit manager (PBM) to ensure the accuracy and timeliness of member’s pharmacy benefit administration driving towards a best in class member experience.


·       Develops in-depth understanding of and ability to create and maintain plan/benefit design rules and limitations to include:

o   Adjudication rules

o   Clinical rules

o   Payment rules

o   Plan/group management

·       In collaboration with The Health Plan Sales and Product teams, assist in developing pharmacy benefit plan designs, ensuring the plan designs meet client requests, Health Plan strategic/ business parameters and all regulatory and other oversight agencies’ requirements.

·       Responsible for creating and maintaining plan/benefit design documentation to support internal and external requirements

·       Leads communication and coordination between Health Plan and PBM for receipt of required information for claims adjudication system set up, reporting and claim adjudication process. This includes:

·       Assessment of all requests for new/ changes to plan benefit information to ensure compatibility with PBM claim adjudication logic

·       Submission of accurate and complete requests to the PBM for new and changing benefit plan designs

·       Serves as liaison to PBM to troubleshoot and resolve benefit related questions/ issues, researching plan/benefit design options and requirements. Participate in PBM implementation meetings as required

·       Review and approval of  PBM benefit set up requirements

·       Perform claim testing to ensure accurate claim adjudication.

·       Work with the pharmacy clinical team to implement formulary updates in the claim adjudication system.

·       Participates in the research and resolution of claims adjudication related discrepancies, errors, and problems.

·       Acts as a resource to Health Plan operational areas in support of the pharmacy claims adjudication process and responding to issues related to plan/ benefit design.  

·       Makes recommendations to streamline the work processes and systems that impact plan/ benefit design to create efficiency and quality outcomes.

·       Maintain acceptable and appropriate quality levels and production SLA response time.

·       Performs other projects and duties as assigned.



  • Pharmacy Technician Certification required.
  • Bachelor's Degree; additional years of related experience may be used in lieu of Degree
  • 3-5 years people management experience, preferably in a call center environment.
  • Excellent people management skills
  • Knowledge of Pharmacy, Managed Care and Self-Insured healthcare products highly preferred 
  • Ability to perform in office environment with extended periods of sitting, using telephone, and viewing computer screens.
  • Ability to prioritize tasks daily and trouble shoot urgent customer issues to successful completion.
  • Advanced knowledge of Microsoft Office applications including Excel and Outlook.
  • Exceptional problem solving, analytical, interpersonal and communication skills to resolve issues within Operations.
  • Professionally skilled in verbal and written communication.
  • Meticulous organization skills, with the ability to multi-task, and ability to make sound decisions in a timely and independent manner.

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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