The Pharmacy Operations Coordinator is responsible for performing oversight and monitoring of the pharmacy benefit manager (PBM), for activities related to the appropriateness of claims adjudication, and for providing support of CMS regulatory requirements, and other Plan Operations.
ESSENTIAL JOB DUTIES:
To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.
- Serve as primary contact between Plan and PBM
• Perform PBM oversight and monitoring
- Report and escalate performance deficiencies and status to management and the compliance department
- Formulary Management: Recognize formulary requirements: non-formulary, prior authorization (PA), Step Therapy (ST), Quantity Limit (QL) and review, outreach, and track rejected pharmacy claims
- Responsible for ensuring regulatory requirements are met for coverage determinations/redeterminations
• Lead annual readiness
- Serve as a liaison with Enrollment Department to ensure appropriate member eligibility processing
- Support CMS Plan reporting, audits, and monitoring activities and submissions
- Assist and track in-coming calls from agents, pharmacies, nursing homes, providers/nurses, and members
• Coordinate monthly website updates
- Monitor and report on departmental metrics
- May be assigned to work on special projects and business initiatives
• Other duties as assigned
JOB REQUIREMENTS:
- Maintain regular and reliable attendance
• Attention to detail
- Ability to work in a high demand fast pace environment
- Experience in planning and implementation
• Strong analytical skills
- Strong leadership and collaboration skills
- Extensive knowledge in Medicare compliance
• Customer and quality focus
- Follow-up and solve any open items in a timely manner
• Adhere to all compliance requirements
- Adhere to Centers of Medicare and Medicaid Services (CMS) regulations
- Successful completion of required training
• Handle multiple priorities effectively
• Independent discretion/decision making
• Make decisions under pressure
REQUIRED QUALIFICATIONS:
• Education:
o High school diploma or equivalent required
• Experience:
o Experience in the pharmacy department of a Medicare Advantage or Part D plan is preferred
• License/Certification(s):
o Pharmacy technician
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