Operations specialist Jobs in Philadelphia, PA

Pharmacy Operations & Claims Reconciliation Analyst

The Pharmacy Operations & Claims Reconciliation Analyst is responsible for supporting the operational, financial, and analytical functions of USUP's pharmacy program through claims reconciliation, reimbursement analysis, operational reporting, and performance monitoring.

This role serves as a key member of the Pharmacy Operations team, partnering with pharmacy leadership, cancer operations leadership, finance, contracting, and external payer/PBM partners to ensure claims accuracy, identify reimbursement opportunities, support operational decision-making, and drive continuous process improvement.

This role is intended to support the continued growth of USUP's pharmacy and medically integrated dispensing programs through data-driven operational support, claims reconciliation, reimbursement monitoring, and business analytics.

Claims Reconciliation & Payment Integrity

• Reconcile pharmacy claims between dispensing systems, PBM remittance files, adjudication systems, vendor reports, and financial records.
• Identify underpayments, overpayments, duplicate payments, reversals, and missing transactions.
• Investigate reimbursement discrepancies and perform root cause analyses.
• Validate claim payments against contractual reimbursement methodologies and payer agreements.
• Coordinate with PBMs, payers, pharmacies, and internal stakeholders to resolve payment discrepancies.
• Support recovery efforts for identified reimbursement variances and payment integrity opportunities.

Pharmacy Operations Analytics

• Develop, maintain, and distribute operational dashboards and reports related to pharmacy performance, prescription volume, payer mix, reimbursement trends, and key performance indicators.
• Analyze pharmacy operational data to identify trends, opportunities, and areas for improvement.
• Monitor prescription conversion rates, referral patterns, dispensing performance, and patient access metrics.
• Support pharmacy leadership with ad hoc analyses, business reviews, and strategic initiatives.
• Identify and recommend process improvements that enhance operational efficiency and financial performance.
• Assist in the development and monitoring of pharmacy operational KPIs and scorecards.

Reimbursement & Contract Performance Analysis

• Monitor payer and PBM reimbursement performance across pharmacy programs.
• Analyze reimbursement trends, fee structures, and contract performance.
• Support pharmacy leadership in evaluating reimbursement changes and financial impacts.
• Assist with payer and PBM performance reviews through data analysis and reporting.
• Identify opportunities to improve reimbursement outcomes and reduce revenue leakage.

Reporting & Documentation

• Prepare reconciliation reports, variance summaries, executive reporting, and issue logs.
• Maintain detailed documentation of findings, investigations, corrective actions, and resolutions.
• Support internal and external audits by providing reconciliation documentation and analytical support.
• Ensure data integrity and consistency across reporting platforms and operational systems.
• Assist in developing standardized reporting and reconciliation procedures.

Required Qualifications

Education & Experience

• Bachelor's degree in Business, Finance, Healthcare Administration, Analytics, Pharmacy, or related field.
• 12 years of experience in pharmacy operations, healthcare operations, claims processing, healthcare analytics, medical billing, reimbursement support, or a related analytical role.

Technical Skills

• Experience working with healthcare, pharmacy, or claims data.
• Proficiency in Microsoft Excel, including Pivot Tables, VLOOKUP/XLOOKUP, formulas, filtering, and data analysis.
• Strong analytical, problem-solving, and organizational skills.

Analytical & Professional Skills

• Strong attention to detail and commitment to data accuracy.
• Ability to investigate discrepancies and communicate findings clearly.
• Excellent written and verbal communication skills.
• Ability to manage multiple priorities and meet deadlines.
• Comfortable working cross-functionally and with external vendors.
• Ability to work independently while supporting a collaborative team environment.

Preferred Qualifications

• Experience with specialty pharmacy, physician dispensing, infusion pharmacy, oncology pharmacy, or ambulatory pharmacy operations.
• Familiarity with pharmacy claims adjudication, PBM reimbursement methodologies, and payment integrity processes.
• Experience supporting claims reconciliation, reimbursement analysis, or financial variance investigations.
• Exposure to payer contracting, PBM contract analysis, or reimbursement modeling.
• Experience developing dashboards and operational reporting.
• Working knowledge of SQL for data extraction and analysis.
• Experience using Power BI, Tableau, or similar reporting and business intelligence tools.
• Knowledge of Medicare Part D, Medicaid, and commercial pharmacy reimbursement programs.
• Understanding of NCPDP transaction standards and pharmacy claims processing.

Key Performance Indicators

• Timeliness and accuracy of claims reconciliations.
• Identification and resolution of reimbursement discrepancies.
• Value of reimbursement variances identified and recovered.
• Timeliness and quality of operational reporting and analytics.
• Reduction in recurring reconciliation variances.
• Successful support of audits, financial reviews, and operational initiatives.

Salary Range

$52,000 - 65,000 annual salary

The compensation range listed reflects the anticipated base pay for this position. Actual compensation will be determined based on factors such as relevant experience, education, skills, and work location.

What We Are Offer You

At U.S. Urology Partners, we are guided by four core values. Every associate living the core values makes our company an amazing place to work. Here "Every Family Matters"

Compassion

Make Someone's Day

Collaboration

Achieve Possibilities Together

Respect

Treat people with dignity

Accountability

Do the right thing

Beyond competitive compensation, our well-rounded benefits package includes a range of comprehensive medical, dental and vision plans, HSA / FSA, 401(k) matching, an Employee Assistance Program (EAP) and more.

About U.S. Urology Partners

U.S. Urology Partners is one of the nation's largest independent providers of urology and related specialty services, including general urology, surgical procedures, advanced cancer treatment, and other ancillary services. Through Central Ohio Urology Group, Associated Medical Professionals of NY, Urology of Indiana, and Florida Urology Center, the U.S. Urology Partners clinical network now consists of more than 50 offices throughout the East Coast and Midwest, including a state-of-the-art, urology-specific ambulatory surgery center that is one of the first in the country to offer robotic surgery. U.S. Urology Partners was formed to support urology practices through an experienced team of healthcare executives and resources, while serving as a platform upon which NMS Capital is building a leading provider of urological services through an acquisition strategy.

U.S. Urology Partners is an Equal Opportunity Employer that does not discriminate on the basis of actual or perceived race, creed, color, religion, alienage or national origin, ancestry, citizenship status, age, disability or handicap, sex, marital status, veteran status, sexual orientation, genetic information, arrest record, or any other characteristic protected by applicable federal, state or local laws. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.