Lead Pharmacy Claims Processing Administrator

Sacramento, CA

Job Description

This position is the subject matter expert of the plan administration team, specializing in the analysis and problem solving of complex benefit design requirements. This role requires strong attention to detail, extensive pharmacy benefits administration knowledge, and well-honed analytical skills to assist both internal and external stakeholders in implementing and maintaining plan benefits. The success of this role will rely heavily on establishing and fostering strong internal and external relationships. Must be comfortable and proficient in presenting complex technical benefit solutions to a wide variety of audiences. Responsible for accurately configuring pharmacy benefits in the various claims adjudication systems across multiple liens of pharmacy business (Medicare Part D, Employer, Government, Coupons, Managed Medicaid, Migrations, etc.) Identifies benefit configuration issues while working with other team members throughout Magellan, ensuring plan benefits are configured based on customer and regulatory requirements.
  • Analyzes new business plans and/or changes to existing business in order to establish the appropriate structure required for claims payment, reporting, innovation projects, etc.
  • Programs the pharmacy benefit formularies, clinical utilization programs, pricing and benefit rules into the various adjudication platforms from information received from configuration analysts using both manual and automated procedures, ensuring that benefits are loaded in a consistent manner across plans.
  • Coordinates activities of the pharmacy benefit administration team; recommends measures to improve performance, programs and efficiency.
  • Efficient and effective distribution of tasks to team, using clear and concise instructions and expectations.
  • Maintains an in-depth working knowledge of departmental workflows and system architecture and the impact to claim behavior as well as downstream departments.
  • Reviews closed cases to ensure department policies and procedures were followed.
  • Prepares updates and reports, including those required for internal/SOX audits.
  • Collaborates between departmental business owners, end users, IT, Contact Center, Claims and Clinical departments to resolve issues, or develop small to large sized new programs. Participates in full life cycle of projects impacting Plan Administration by performing requirements analysis, process development and design, and unit testing. Participates in initiatives or projects that support process improvements, leveraging new system capabilities or the integration of data/other applications into existing systems.
  • Responsible for mentoring and training team members.
  • Works closely with IT claims system staff to develop product design and changes through enhancements, ensuring they adequately meet claims processing needs.
  • Provides input on specifications related to CORE system changes and/or enhancements.
  • Works with senior level management to implement recommended changes.
  • Works with QA Department to enhance processes that provide efficiency and accurate testing while meeting agreed upon deliverable dates.
  • Acts as point of contact for drug compendia file load issues or global changes.
  • Leads special projects and/or system enhancements.
  • Other duties as assigned.


General Job Information


Lead Pharmacy Claims Processing Administrator



Job Family

Operations Group


United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date


Date Requisition Created


Work Experience

Benefit Plan Administration, Claims, Formulary Management, Medicare Part D (MedD), Pharmacy


Bachelors (Required)

License and Certifications - Required

License and Certifications - Preferred

CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy

Other Job Requirements


  • Advanced working knowledge of Microsoft office products (specifically Word, Access, Excel), including running queries and macros.
  • Experience in interpreting and understanding codes/benefits.
  • Experience with claims processing systems and configuring codes/benefits to optimize auto-adjudication across multiple lines of Pharmacy Benefit Management (PBM) business.
  • Ability to identify and resolve process and/or systems issues.
  • Strong sense of urgency leading to the timely completion of all projects, training and assignments.
  • Travel requirements of up to 10%.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.