The Pharmacy Benefit Coord serves in a key role in the development, implementation and management of comprehensive and effective pharmacy programs and benefits. Leads clinical and compliance monitoring of all aspects of pharmacy benefit management (PBM) and operational areas, including claim adjudication and benefit analysis, pharmacy benefit implementation and documentation for specific lines of business. Leads workgroups and projects as assigned.
ESSENTIAL FUNCTIONS OF THE ROLE
Acts as a Subject Matter Expert (SME) for specific lines of business as related to pharmacy benefit programs and operations.
Responsible for urgent and complex adjudication and processing issues including research, analysis, identification of root cause, impact analysis and corrective action, partnering with vendor through resolution.
Conducts moderate to complex data analysis including creating the reports and pulling the data while providing regularly scheduled reporting and communication to management.
Responsible for implementing and ensuring accuracy of pharmacy plan designs and clinical programs.
Routinely interacts with vendors and internal stakeholders to coordinate benefits, resolve access to care issues, operationalize clinical programs, and ensure compliance with standards defined by the Health Plan and regulatory governing bodies.
Responsible for education and training of staff regarding pharmacy benefit requirements, processes and key projects, promoting best practices.
Leads implementation testing of new functionality to ensure desired outputs. Prepares test scenarios and executes testing. Assists with development of report mapping and generates required data reports for audits.
Responsible for review of standard and ad-hoc reports to confirm compliance with Health Plan, regulatory and accreditation standards, address gaps and ensures sound operations. Assists with preparation for and serves as subject matter expert in audits conducted by regulatory and accreditation bodies.
Interprets and accurately applies regulatory requirements that are applicable to the job function.
KEY SUCCESS FACTORS
Certified Pharmarcy Technician (CPHT) preferred.
Ability to lead and delegate tasks through other team members.
Demonstrated ability to manage multiple priorities and deadlines in a fast-paced environment.
Problem-solving, critical thinking skills and attention to detail a must.
Well-organized and self-directed individual who is able to work with minimal amount of supervision.
Sound technical skills and analytical ability, advanced ability to apply reasoned judgment, and strong operational focus.
Advanced proficiency in Microsoft Office and in a variety of industry related software programs.
Knowledge of PBM operations, formulary management and utilization management edits preferred.
Knowledge of drug nomenclature, basic pharmacology, dosage calculations, units of measure, prescription filing techniques, prescription documentation requirements, pharmacy laws and regulations, basic managed care principles and insurance coverage issues.
Knowledge of multiple clinical pharmacy resources.
Ability to interact and maintain professional working relationships with internal and external partners to coordinate benefits and services.
Demonstrates professional business acumen including attendance, adherence, attitude and behavior.
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
- EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification
- EXPERIENCE - 3 Years of Experience