Duties & Responsibilities:

• Identifies opportunities for improvement and participates in the development of new pharmacy reporting capabilities to maximize performance

• Supports operations, member experience, and FWA initiatives in collaboration with the Pharmacy Operations team

• Collaborates with Medicare product team to identify and implement benefit solutions to promote quality and achieve cost savings

• Participates in the setup and monitoring of Medicare Pharmacy benefits and PDE accuracy in collaboration with out Pharmacy Benefit Manager (PBM)

• Monitors and analyzes key data and procedures for proper claims processing and adjudication system functionality

• Performs Quality Control and Quality Assurance functions to assess information accuracy prior to report distribution

• Partners with Enrollment and Billing to establish processes to reconcile enrollment and eligibility data used to effectuate appropriate access to prescription drug benefit

• Provides timely support to other areas to verify and analyze claims processing cases, eligibility and other operational situations and/or issues as they relate to delegated functions

• Reviews CMS communications related to Medicare Part D and leads implementation/response planning

• Acts as HFs Pharmacy PDE Subject Matter Expert (SME)

• Manages weekly CMS PDE reports to:

• Facilitate PDE resolution

• Analyze PDE reporting to ensure accuracy

• Manages any new PDE and claims processes related to Medicare policy updates, audit findings, and benefits changes

• Participates in and supports the annual Medicare bid and Go-To Market projects in collaboration with the Medicare Pharmacy team

• Manages primarily internal projects between Pharmacy and other HF business units, including Enrollment and Billing, IT, Enterprise Analytics, Regulatory, Population Health

• Track projects to target

• Coordinate meetings with and collect deliverables from appropriate teams

• Capture action steps

• Communicate to leadership

• Performs regulatory monitoring Medicare Pharmacy benefits operations

• Maintain compliance with all State and Federal agencies

• Additional duties as assigned

Minimum Qualifications:

• High school diploma or GED

• PC Skills with Microsoft Word, PowerPoint (creating presentations and slides), and Excel (Pivot tables), MS Access

• Basic SQL skills; able to build simple queries

• Experience working with a Pharmacy Benefit Manager (PBM) within a health plan or direct experience at a PBM that includes client facing interaction

• Ability to communicate clearly both verbally and in writing

• Demonstrated critical thinking and problem-solving skills

• Ability to lead large and small working meetings

• Passion for learning, promoting access to healthcare, and interest in growing skills in a dynamic environment with various opportunities

Preferred Qualifications:

• Bachelors Degree or 3-5 years of managed care experience

• Knowledge of PBM

• Certified pharmacy technician

• Knowledge of regulations of the Centers for Medicare and Medicaid Services and the New York State Department of Health

• Knowledge of Prescription Drug Events (PDEs) and billing practices in the medical and pharmacy benefits

• Experience with pharmacy benefit management oversight including maintaining policies and procedures

• Pharmacy benefits installation and testing experience

Regulatory or Compliance activities:

• Assists in regulatory and compliance audits for all plans. Ensure all activities are conducted in compliance with regulations.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.