This is a highly responsible position which requires in-depth working knowledge of all pharmacy vendors, including multiple PBM’s, specialty pharmacy, and mail-order. This individual will be expected to resolve most related issues independently with only limited supervision by his/her supervisor. This position will also serve as the point person for Medicaid and Medicare lines of business and assist with the oversight, implementation, development of Pharmacy Services activities and initiatives related to such lines of business.
Responsible for maintaining and updating pharmacy benefit information in databases and the formulary drug lists, and for communicating this information to all internal and external customers. This position will also be responsible to ensure HNE’s compliance with all standards, policies & procedures and conducting audits, including but not limited to NCQA and CMS.
The following duties represent 60% of this role:
Medicaid/Medicare Program Support
• Serve as the Medicaid operational point person for HNE’s Medicaid patient centered medical homes (PCMH Brightwood, Mason Square & High)
• Represent HNE at business and community sponsored (e.g. Medicaid/Medicare educational events)
• Present pharmacy program highlights at intro meetings
• Present data and follow up on process improvement on a quarterly basis
• Work collaboratively with Director of Pharmacy, Clinical Pharmacists, and Pharmacy Supervisor on key initiatives to improve operations and education between HNE and PCMH’s
• Work collaboratively with EOHHS and Medicaid Program Manager to develop communications for Medicaid members
• Submit Medicare Part D reports to CMS per their regulations
• Develop and/or update pharmacy reports with respect to medical, retail and specialty vendors for analysis of quality improvement and utilization management.
• Collaborate with the pharmacist for project development and implementation. Prepare, analyze and present Medicare Part D and Medicaid reports to the Clinical Pharmacist(s) and/or Director of Pharmacy.
• Management of correspondence –telephonic, emails, and letters with members and providers regarding all lines of business.
• Understanding of concepts, features, benefits, disclosures and provisions of all lines of business.
• Work with key stakeholder areas (e.g. compliance, member service, clinical services, etc.) to resolve inter-departmental issues.
• Review PBM pharmacy reports to identify opportunities for improvement with a primary focus to improve service and evaluate proper compliance.
• Conduct monitoring of drug edits with a primary focus on government program but not limited to.
• Work with PBM(s) to provide oversight of appropriate pharmacy configuration of benefits and formularies.
• Work collaboratively with PBM to ensure compliance with pharmacy manufacturer to maximize rebates
• Special projects as assigned by Pharmacy Services Supervisor, Clinical Pharmacist and/or Pharmacy Director including but not limited to: employer group fairs, IT initiatives, development of member and provider communications.
• Provider outreach and education including onsite visits.
• Assist with delegated entities by reviewing activity reports and preparation of monthly and quarterly meetings for all lines of business.
• Conduct monitoring of medication edits to ensure appropriate configuration
• Accountable for development of 60 day notice changes
Compliance with Policy and Procedures 30%:
• Perform audits to assure compliance and oversight on the following: SNF Reporting, drug plan finder monitoring, weekly rejected claims, transition reporting, Part D grievances, coverage gap, EOB monitoring, weekly processed claims, etc.
• Daily auditing of Prior-Authorization (PA) Denial Letters
• Ensure compliancy of PA delegated criteria with the PBM
• Conduct monthly audit meetings between HNE and PBM
• Maintain and update all Pharmacy Policies & Procedures into HNE’s Compliance 360 database for all lines of business
• Assist Clinical Pharmacist with Pre and Post administrative responsibilities associated with the preparation of the Pharmacy and Therapeutics Committee (CCAC).
Maintaining, Educating, and Coordination of multiple drug formulary listings to all internal & external customers 10%:
• Drug Updates from the PBM
• Pharmacy Services Database
• HNE Intranet, Member Services Homepage and SharePoint
• Provider Manual(s)
• Management of Pharmacy Website, HNE.com
• Member Formulary Listing, including all tables and grids
• Assist with informing members thru letters and newsletters.
• Provide training for Member Services staff, new employment on PBM system, and pharmacy tools
|Associates Degree in Health Care, Pharmacy or a related field with a minimum of 4 years’ experience in a pharmacy or managed care environment or an equivalent combination or education and experience.
• Pharmacy Technician Certification or equivalent preferred
• Good understanding of CMS standards as applied to Medicare Part D
• Project management experience preferred
• Conflict resolution and negotiation skills
• Demonstrated problem solving and critical thinking skills
• Multi-tasking and detail oriented skills
• Capable of working independently or as a team member in a fast paced environment
• Advance capabilities with computer systems and applications – Microsoft Office Suite experience
• Excellent written, verbal communications and listening skills
• Ability to effectively interact with a multi-cultural membership
• Organizational agility
• Experience with medical and pharmacy terminology preferred
• Skilled with Infopath and Adobe Acrobat X
|• Office Environment
• Must be able to sit for extended periods of time
• Must be able to work at a personal computer for extended periods of time