Address
Form of workWhy This Role is Important to Us
The Pharmacy Operations Specialist is responsible for supporting the operational functions of Commonwealth Care Alliance (CCA) pharmacy program. Operational functions include; formulary management, quality assurance, regulatory and compliance Primary responsibilities include managing pharmacy operations initiatives, policy development and maintenance, formulary review and analysis, and ensure team meets all regulatory and quality standards/timelines. The specialist will process all pharmacy related inquiries, including but not limited to operations, clinical, utilization management, and regulatory. This position requires someone who is highly organized, detail-oriented, personable, and able to adapt to a dynamic environment.
What You'll Be Doing
FORMULARY MANAGEMENT
• Responsible for all administrative components of formulary creation, development, and maintenance.
• Non-clinical subject matter expert (SME) of CCA formularies
• Create, maintain, submit, and post formularies using formulary management tool for all lines of business
• Partner with key stakeholders to provide oversight and monitoring of formulary marketing materials, claims adjudication testing, and participation in weekly PBM calls.
• Support pharmacy operations team in the analysis of monthly and yearly formulary submissions.
• Conduct scheduled and ad hoc comparisons of competitor drug coverage for all lines of business
QUALITY ASSURANCE/REGULATORY
• Complete quality assurance activities to ensure work meets regulatory requirements
• Participate and provide support for internal and government audits
• Participate in internal work groups as required (e.g. FWA, Member Services)
• Develop and maintain pharmacy operations workflows, job aids, and training materials as required
• Support resolution of member grievances as needed
• Act as pharmacy operations liaison with internal CCA departments as designated
• Develop materials and educate internal departments on pharmacy operations as deemed necessary
• The specialist will process inbound calls, faxes and any other defined method of pharmacy appeal transmission from providers and members to process appeal requests (temporary).
CLINICAL PHARMACY SUPPORT
• Communicate and obtain pertinent information for consultation from members, physician offices and care managers
• Document notes in the appropriate tracking system
• Provide administrative support to clinical pharmacists by outreaching members/providers to improve medication management (e.g. 90 day supply) as needed
• Provide a variety of administrative functions to support care management programs
• Track and formally respond to pharmacy related inquiries from internal and external stakeholders
• Support department initiatives and projects as assigned
• Serve as a resource to others within the department.
What We're Looking For
• Associate degree in Healthcare, Nursing, Pharmacy or a related area or equivalent experience required
• Bachelor's degree preferred
• Certified Pharmacy Technician (CPhT) preferred
• Minimum of 2 years of experience in health care or health insurance industry preferred.
• Experience in retail, hospital, or managed care pharmacy industry required.
• Experience working with Medicare Parts B and D and/or Medicaid Plans preferred
The Pharmacy Operations Specialist is responsible for supporting the operational functions of Commonwealth Care Alliance (CCA) pharmacy program. Operational functions include; formulary management, quality assurance, regulatory and compliance Primary responsibilities include managing pharmacy operations initiatives, policy development and maintenance, formulary review and analysis, and ensure team meets all regulatory and quality standards/timelines. The specialist will process all pharmacy related inquiries, including but not limited to operations, clinical, utilization management, and regulatory. This position requires someone who is highly organized, detail-oriented, personable, and able to adapt to a dynamic environment.
What You'll Be Doing
FORMULARY MANAGEMENT
• Responsible for all administrative components of formulary creation, development, and maintenance.
• Non-clinical subject matter expert (SME) of CCA formularies
• Create, maintain, submit, and post formularies using formulary management tool for all lines of business
• Partner with key stakeholders to provide oversight and monitoring of formulary marketing materials, claims adjudication testing, and participation in weekly PBM calls.
• Support pharmacy operations team in the analysis of monthly and yearly formulary submissions.
• Conduct scheduled and ad hoc comparisons of competitor drug coverage for all lines of business
QUALITY ASSURANCE/REGULATORY
• Complete quality assurance activities to ensure work meets regulatory requirements
• Participate and provide support for internal and government audits
• Participate in internal work groups as required (e.g. FWA, Member Services)
• Develop and maintain pharmacy operations workflows, job aids, and training materials as required
• Support resolution of member grievances as needed
• Act as pharmacy operations liaison with internal CCA departments as designated
• Develop materials and educate internal departments on pharmacy operations as deemed necessary
• The specialist will process inbound calls, faxes and any other defined method of pharmacy appeal transmission from providers and members to process appeal requests (temporary).
CLINICAL PHARMACY SUPPORT
• Communicate and obtain pertinent information for consultation from members, physician offices and care managers
• Document notes in the appropriate tracking system
• Provide administrative support to clinical pharmacists by outreaching members/providers to improve medication management (e.g. 90 day supply) as needed
• Provide a variety of administrative functions to support care management programs
• Track and formally respond to pharmacy related inquiries from internal and external stakeholders
• Support department initiatives and projects as assigned
• Serve as a resource to others within the department.
What We're Looking For
• Associate degree in Healthcare, Nursing, Pharmacy or a related area or equivalent experience required
• Bachelor's degree preferred
• Certified Pharmacy Technician (CPhT) preferred
• Minimum of 2 years of experience in health care or health insurance industry preferred.
• Experience in retail, hospital, or managed care pharmacy industry required.
• Experience working with Medicare Parts B and D and/or Medicaid Plans preferred
- Proficiency in MS Office: Excel, Word, and PowerPoint required MS Visio experience preferred
- Must have excellent oral and written communication skills, including preparation of presentation-ready materials.
- Excellent analytical skills necessary to interpret pharmacy data and reports
- Proven time management and organizational skills.
- Ability to manage multiple tasks, workflows and responsibilities that can vary significantly across business lines. Capable of working in a fast-paced environment while maintaining accuracy in all elements of the position.
- Must be detail oriented, be able to work independently, and must have solid self-motivation skills
- Bilingual (Spanish) preferred
