Manager, Pharmacy Operations

SCAN Health Insurance•Long Beach, CA

3d•Remote

About The Position

The Manager of Pharmacy Operations is responsible for providing leadership and direction to the pharmacy operations team while working cross-functionally with other departments and the Pharmacy Benefit Manager (PBM) on CMS, DHCS, and other states regulatory requirements. The role ensures regulatory compliance related to prescription drug event (PDE) data, Drug Plan Finder processes, financial information reporting, Part D reporting, pharmacy benefit configuration and testing, and plan benefit package reviews during BID submission. It provides support during CMS Part D and other regulatory audits (e.g., 1/3 financial audit, National MEDIC audits) and ensures Part D deadlines and timeframes are met. This position supports pharmacy leadership to drive departmental and organizational goals. This position oversees pharmacy benefit administrators and pharmacy analysts, providing leadership, direction, and fostering continuous team development.

Requirements

Five (5) years or more of Medicare Part D experience with a health plan or PBM required.
Three (3) years of leadership experience in a managed care setting with full scope of supervision for non-licensed staff.
Three (3) years or more of experience in data analysis required.
Bachelor's Degree or equivalent experience - Business/Healthcare.
Expert in Medicare Part D.
Knowledge of CMS Part D regulations e.g., CMS Call Letters, MAPD application, Claims Processing, Part D Reports.
Ability to create, develop and implement process improvement and the ability to instill that focus in a team.
Ability to work cross-functionally and collaboratively across the organization.
Technologically savvy and able to utilize information systems effectively (MS Office - Word, Excel, PowerPoint, Access, Visio, Outlook; SQL)
Ability to manage and adapt to a significant change.
Strong interpersonal skills, including excellent written and verbal communication skills.
Strong organizational skills; ability to multitask and meet multiple competing deadlines.
Ability to appropriately maintain confidentiality.
Strong analytical and critical thinking skills.
Ability to research, analyze, and problem solve.
Self-starter that can take the lead on a project and manage its progress for completion.

Nice To Haves

Active Pharmacy Technician License preferred.

Responsibilities

Ensure regulatory compliance with respect to prescription benefits set up and year-round CMS Program Audit, 1/3 Financial audit, National MEDIC, and other audits readiness; Provide leadership and support during all CMS Regulatory Audits related to pharmacy operations; e.g., ensure accuracy of written responses and/or documentation for the pharmacy audits; Ensure audit documentation is prepared according to audit instructions and provided within the specified audit timeframe; Prepare written responses or documentation for pharmacy audits.
Serve as a subject matter expert for Part D Reporting requirements, Pharmacy Access Requirements, Prescription Drug Event data, Financial Information Reporting and Drug Plan Finder files by keeping up to date with Medicare requirements; Maintain current knowledge of Medicare Part D regulations by participating in CMS calls and reading released guidance and implementing changes to maintain compliance.
Oversee the accurate implementation and maintenance of pharmacy benefits, pharmacy account structure, pharmacy network, including GEO access requirements; Lead the team to review and ensure the accuracy of the Pharmacy Benefits for the annual BID submission to CMS; Ensure Annual Enrollment Period (AEP) and 1/1 operational readiness and assist in training of other departments on Pharmacy products.
Lead automation efforts related to the Prescription Drug Event, Benefits Configuration and Testing Initiatives; Analyze and monitor large data sets that are exchanged from SCAN to the PBM using a variety of reporting tools.
Accountable for ensuring eligibility and coordination of benefit files are sent to the PBM for processing and assess if file enhancements are needed; Ensure the PBM is processing Prescription Drug Events, Automated Claims Reprocessing and Financial Information Data according to CMS regulatory standards by conducting daily oversight; Ensure PBM oversight of claims adjudication; Oversee PBM operations to ensure high service level to SCAN and our members; Maintain strong rapport with PBM representatives such that team’s goals and needs are met.
Prepare documentation for Service Area Expansion application submission to CMS.
Support Part C and Part D Data Validation audits, including Medicare Prescription Payment Plan Module.
Participate in Medicare Plan Finder testing and other CMS-related activities.
Collaborate with other SCAN departments: Compliance, Marketing, Digital, HCI, Product, Finance and Member Services by participating in cross-functional meetings and supporting achievement of team’s goals; Foster strong relationships with internal departments and external providers.
Identify operational gaps and work with the staff or PBM by providing feedback/recommendations on how to fix operational gaps and ensures follow through; Resolve issues and monitor results of daily staff activities, keeping management informed of key issues and problems as encountered.
Develop, implement, and maintain department’s policies and procedures, desktop procedures and standard operating procedures to ensure ongoing compliance; Instill a culture of continuous process improvement, efficiency, collaboration, operational excellence and compliance amongst team.
Provide Pharmacy Analyst and Pharmacy Benefits Administrator team support by communicating job expectations, giving continual feedback, enforcing policies and procedures, and conducting training programs; Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching and counseling employees; initiating, coordinating, and enforcing systems, policies, and procedures; Maintain staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; developing personal growth opportunities.
Conduct training sessions of the pharmacy benefit and Part D programs to other departments as needed; Train staff on job-related functions and refresher courses as updates to processes or requirements occur.
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.

Benefits

Base salary range: $80,300 to $116,197 per year.
An annual employee bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
11 paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
Excellent 401(k) Retirement Saving Plan with employer match and contribution
Robust employee recognition program
Tuition reimbursement
A competitive compensation and benefits program
An annual employee bonus program
Generous paid-time-off (PTO)
Eleven paid holidays per year
Excellent Retirement Savings program
A work-life balance
An opportunity to become part of a team that makes a difference to our members and our community every day!