Join a team where values drive vision.

Posted

September 2026

Job type

Full-time

Location

Remote

Schedule

Monday to Friday

Supplemental pay

Bonus pay

Essential job functions

• Analyze standard and customized PBM coding requests and work with internal teams to obtain accurate and complete plan documentation needed to code client intent into the pharmacy claim adjudication system in a timely manner.
• Implement new and maintain existing client hierarchies, benefit plans, pricing, formularies, and networks in the pharmacy claim adjudication system, consistent with the direction and intent set forth by the client or MaxCare.
• Maintain the MaxCare formularies and clinical program offerings in the pharmacy claim adjudication system.
• Perform pre- and post-implementation claim testing and other configuration quality reviews to ensure accurate claim adjudication and adherence to standard and custom design requirements.
• Identify discrepancies, inaccuracies, and unintended consequences, and take corrective action.
• Research and respond to claims processing and system configuration inquiries from internal departments.
• Proactively identify setup service issues and escalate to Operations Director for immediate review and resolution.
• Accurately configure non-adjudicated services and fees across multiple systems.
• Support QA and Audit staff and functions.
• Project management.

Additional responsibilities

• Perform other duties and projects as required by management.
• Complete department or corporate projects as assigned.

Minimum qualifications for consideration

• Associate degree or equivalent combination of education and job-related experience.
• Requires at least 5 years of experience in pharmacy benefits or pharmacy/medical processing experience.
• Strong understanding of pharmacy benefit plans including copays and out-of-pockets, drug coverage, accumulators, pharmacy network, billing/payment methodologies, formulary, and PBM industry standards.
• Prior PBM experience in a benefit configuration/setup role.
• Experience in claim testing and quality assurance.
• Knowledge of PBM configuration system(s).

Knowledge, skills and abilities

• Strong follow-through on projects and deliverables.
• Strong analytical and problem-solving skills.
• Excellent verbal and written communication skills.
• Good interpersonal skills: able to work well with a wide range of people.
• Strong organizational and time management skills.
• Demonstrate dependability through good attendance and adherence to timelines and schedules.
• Demonstrate resourcefulness and ability to take initiative in development and completion of projects.
• Strong sense of customer service.
• Strong proficiency in MS Office applications.

Benefits

• Health insurance
• Dental insurance
• Vision insurance
• Flexible spending account
• Life insurance
• Paid time off

Application question

Do you have standard and custom system coding, maintenance, and quality assurance experience in a pharmacy claim adjudication system? We are seeking an individual with direct experience related to standard and custom plan designs, pricing, clinical programs, and pharmacy networks.

The above statements are intended to describe the general nature and level of work performed by an employee in this position. These statements are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of employees in this position.

Posted

September 2026

FLSA

Exempt

Reports to

Vice President, MaxCare

Location

Remote eligible

Summary

The Clinical Services Director is responsible for the management and coordination of clinical programs within MaxCare. This role oversees clinical services personnel, optimizes daily prior-authorization workflows, assigns client-specific reporting and inquiries, and implements quality assurance and quality-improvement strategies across MaxCare’s clinical programs.

Essential job functions

Departmental leadership and strategy

• Set the clinical services department’s strategic goals, mission, and vision annually to align with MaxCare’s strategic goals, mission, and vision.
• Continuously assess, evaluate, and communicate clinical services personnel’s performance against individual and departmental goals and their job descriptions.
• Oversee clinical pharmacists and technicians regarding work performed and administered within MaxCare’s clinical programs.

Clinical program and utilization management oversight

• Support the clinical services team in the review and decision of prior-authorization requests based on clinical criteria, per national, state, and internal MaxCare standards.
• Develop and maintain drug utilization management programs and policies, guidelines and criteria governing prior authorizations, appeals, quantity limits, step therapies, age/gender limits, and other clinical programs.
• Implement quality assurance and quality-improvement strategies for MaxCare’s clinical programs.
• Continuously evaluate ways to streamline and improve the quality of the drug utilization management process.

Client consultation and industry trends

• Work with the account management and sales team to provide clinical program consultation and recommendations to clients for benefit implementation.
• Collaborate with clients and account managers to design custom management programs, including cost-savings analysis, claims-data analysis, and clinical recommendations.
• Stay current with emerging trends in formulary utilization-management strategies and the broader healthcare industry.

Additional responsibilities

• Assist in the training and mentoring of pharmacy students, interns, and/or residents.
• Perform other duties and activities as determined by the PPOk Chief Executive Officer or MaxCare Vice President, to support, advocate, and promote independent pharmacy.

Minimum qualifications for consideration

Credentials

• Active pharmacist licensure in good standing with the State Board of Pharmacy, no restrictions, and graduation from an accredited college of pharmacy.
• Residency trained plus a minimum of one year of clinical experience (or, without residency, a minimum of three years of clinical experience).
• Active pharmacy preceptor license.

Education

• Doctor of Pharmacy or B.S. Pharmacy degree from an accredited university.

Experience

• Clinical knowledge in pharmacy benefits management, managed care, or clinical practice settings.
• Proficiency in critical literature evaluation and evidence-based medicine principles.

Knowledge, skills and abilities

• Highly developed leadership, team-management, and project-management capabilities.
• Strong knowledge of healthcare regulations and standards.
• Demonstrated ability to optimize workflows for efficiency and quality.
• Familiarity with prescription benefits claims processing and formulary design.
• Knowledge of the Medi-Span data system, including the GPI drug classification system.
• Strong analytical and problem-solving abilities.
• Exceptional communication and interpersonal skills.
• Customer-service orientation and commitment to professionalism.
• Proficiency in Microsoft Office and relevant data-analysis tools.
• Strong organizational and time-management skills.

Physical requirements

This work is sedentary and may involve occasional bending, squatting, kneeling, and stooping. It requires good finger dexterity, feeling, and frequent repetitive motions, as well as the ability to talk, hear, and maintain visual acuity. Occasional travel to client locations and other sites may be required.

Working conditions

• Office environment.
• Remote work environment: this position is eligible for remote work based on remote work qualifications and maintaining high quality productivity.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Company description

MaxCare Prescription Benefit Services is redefining pharmacy benefit management. We provide clients with the knowledge, clarity of options and flexibility they need to effectively manage pharmacy benefits. We focus on developing programs, services and processes that are clinically based, member-focused, and aligned for all stakeholders. MaxCare delivers an innovative mix of market expertise, information technology, and specialty pharmacy offerings. We serve the needs of health plans, unions, third-party administrators (TPAs) and self-insured employers.

The above statements are intended to describe the general nature and level of work performed by an employee in this position. These statements are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of employees in this position.