Collaboratively develop solutions to departmental strategic and operational requirements. Support all aspects of the pharmacy benefit and work with the Pharmacy team on implementing, and coordinating pharmacy initiatives, including compliance and 5-Star goals. Act as a liaison and information resource to internal and external pharmacy services customers. Manage communications, develop policies and procedures, and generate and review reports to ensure departmental compliance according to PacificSource and regulatory standards. Support department vision by demonstrating effective teamwork, managing change, and encouraging innovation and staff involvement.
Process incoming reports from Centers for Medicare & Medicaid Services (CMS), Oregon Health Authority (OHA) and Prescription Benefit Manager (PBM) take action as needed. .
Support administrative aspects of 5 Star initiatives through mailings, report generation, and other tasks as assigned.
Maintain member, pharmacy and provider communications current with compliance guidance and industry best practices.
Support the maintenance of the pharmacy benefit formulary across lines of business. Maintain website formulary and coverage policies in compliance with CMS timelines and regulations.
Work with Product Development and Pharmacy teams to ensure accurate and optimal pharmacy benefit designs.
Serve as an inter-departmental liaison for benefit configuration and testing.
Provide oversight of PBM operations through the following actions: attending meetings; review and approve external communications; and monitor operational performance. Research and document PBM Service Warranties
Develop Pharmacy department policies & procedures as applicable and ensure regular maintenance to reflect new practices and guidance.
Support Compliance and departmental monitoring, oversight, and audits in the following areas: CDAG, ODAG, CDE, OIG, NCQA; oversight of PBM, MTM and other vendors; and review of technician documentation, coverage decisions and call monitoring.
Support Fraud, Waste, and Abuse (FWA) efforts by identifying cases, conducting preliminary research, and interfacing with the FWA team about findings.
Facilitate pharmacy department training and documentation of best practices.
Facilitate inter-departmental communications about policies, procedures, or operational changes
Generate pharmacy claims reports and dashboards to support other administrative initiatives as directed.
Meet department and company performance and attendance expectations.
Perform other duties as assigned.
Work Experience: Minimum of three years of pharmacy related health insurance experience required.
Education, Certificates, Licenses: High school diploma or equivalent required. Bachelor's degree preferred. Pharmacy Technician Certification required.
Knowledge: Strong computer skills. Excellent verbal and business writing skills. Excellent public relations skills. Good understanding of Medical Terminology required. Requires ability to define and prioritize problems and manage workload with and without direct supervision. Ability to work efficiently and effectively with a high attention to detail.
Building Customer Loyalty
Building Strategic Work Relationships
Contributing to Team Success
Planning and Organizing
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for our customers' experience.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our communities-internal and external.
We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Physical Requirements: Stoop and bend . Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.