Address
Form of workJOB SUMMARY:
This position is responsible for coordinating CMS and ACA related pharmacy directives, monthly EOB processes, various data files and processes that support the pharmacy department, pharmacy formulary notification processes, pharmacy claim audit procedures, Medicare Part D reporting, Medicare Part D document maintenance and various related pharmacy department functions.
KEY RESPONSIBILITIES:
- Pharmacy Claims Audits - conducts daily review of paid and rejected pharmacy claims for all lines of business and completes weekly manual audit of pharmacy claims for all lines of business and requests applicable reports from DAR and PBM to adequately ascertain the accuracy of billed pharmacy claims.
- Formulary Maintenance - works with PBM and clinical pharmacist to manage monthly formulary (FRF) submissions to CMS. Assists with the development, production and audit of formulary files created by the PBM.
- Medicare Oversight Reports - manages and verifies accuracy of Medicare oversight reports provided by PBM and coordinates resolution of issues related to reporting when necessary.
- Coordinates CMS related pharmacy directives with other affected CCOK departments.
- Coordinates with PBM and internal departments to prepare Part D document templates for submission to CMS.
- Website Maintenance - works with internal CCOK partners and PBM to create and coordinate publishing pharmacy benefit materials on CCOK website for all lines of business. Performs oversight for accuracy of pharmacy benefit materials and maintains updates to benefit materials on a frequent basis.
- Coordinates with PBM to identify members/physicians impacted by formulary or pharmacy network changes. Coordinates mailing process including obtaining appropriate approvals from various departments. Coordinates with PBM to include required information in EOB, formulary changes, web posting, and mailing of negative change letters and audits documents before publication. Communicate formulary/RX benefit changes, PBM operational changes, drug shortages, ACR mailings, NSDE drugs and member/provider mailings to internal departments.
- Using PBM reporting tool, create ad-hoc reports as needed.
- Perform other duties as assigned.
QUALIFICATIONS:
- Demonstrated understanding and application of pharmacy claims processing and pharmacy terminology.
- Proficient in Microsoft applications.
- Ability to maintain a positive, professional work environment.
- Successful completion of Heath Care Sanctions background check.
- Possess strong oral and written communication skills.
EDUCATION/EXPERIENCE:
- High school diploma or equivalent. Associates degree preferred.
- Minimum of 3 years work experience in a health care environment, preferably as a pharmacy technician.
CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin
Other details
- Pay Type Hourly
Apply Now
