Pharmacy Services Vendor Specialist - 240721

DESCRIPTIONRESPONSIBILITIES Bring your drive for excellence teamwork and customer commitment to Independence Join us as we renew and reimagine the future of health care Together we will achieve our mission to enhance the health and wellbeing of the people and communities we serve

The Pharmacy Services Vendor Specialist responsibilities includes  Investigate and provide root cause analysis impact and issue remediation for compliance issues  Review supporting documentation to ensure that key OMT indicators identifying compliance are met    Provides direction regarding next steps of issues identified such as letter language Rx authorization overrides member outreach etc  Provides direction for member resolution which includes but is not limited to reimbursements letter generation Rx overrides Rx Grandfathering etc  Support the daily DPR process to identify adjudication issue and escalate appropriately   Support weekly compliance issue resolutions meeting to ensure closure Kathys team delegation oversight PBM  Provide direction to PBM on next steps how to address errors or issues ie reprocessing claims etc   Provides final approval to release reprocessed claims notify PBM  Collect and validate data to support audits Internal NCQA CMS audit selffunded  Collect and validate data to support external vendor audit request to comply with format and audit timeframes   Coordinate with the PBM regarding audit requirements PBM provides data this role reviews the request against what comes back from PBM  If not accurate goes back to PBM  If accurate release the data  Report PBM performance within the performance guarantee process  monitor for the month the PBM performance guarantee  Track and trend metrics and documentation  Conducts daily coverage determinations timeliness review  Conducts daily coverage determination letter QA to ensure accuracy letter generated at PBM and ensuring the compliance oversight of letter  Escalate all findings with recommendations and outlining compliance risks  looking at report of work from PBM the prior day verifying the work was accurate and compliant   If not identify determine regulations identify what failed and outline compliance risks

QUALIFICATIONS Education  Bachelors degree or equivalent work experience

Experience  3 Years related work experience

Knowledge Skills  Medicare andor health plan operations experience preferred  Audit experience  Pharmacy Background preferred

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app

Independence has implemented a Hybrid model which consists of Associates working in the office 3 days a week Tuesday Wednesday  Thursday and remotely 2 days a week Monday  Friday This role is designated as a role that fits into the Hybrid model While associates may work remotely on our designated remote days the work must be performed in the TriState Area of Delaware New Jersey or Pennsylvania

Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer All qualified applicants will receive consideration for employment without regard to their age race color religion sex national origin sexual orientation protected veteran status or disability