Medication Management Specialist

Capital Health Plan•Tallahassee, FL

6d•Onsite

About The Position

Join Capital Health Plan as a full-time Medication Management Specialist to maintain regulatory compliance and ensure we can continue to serve our patients' healthcare needs. Accuracy and attention to detail are crucial in this role, as you'll be directly overseeing the regulatory and accreditation requirements related to the pharmacy benefit. The Medication Management Specialist conducts utilization management reviews for physician-administered and specialty medications covered under the medical benefit, ensuring requests are reviewed in accordance with evidence-based clinical criteria, benefit requirements, and applicable regulatory guidelines. This role collaborates closely with internal clinical teams, providers, and delegated pharmacy benefit partners to promote quality, compliance, and effective medication management for CHP members. You'll ensure that all activities comply with regulations, maintain departmental files, and participate in timely data validation for internal and external audits. You'll also provide oversight for pharmacy benefit manager delegated functions such as formulary administration and coverage determinations.

Requirements

At least 4 years of related experience in a Medicare Advantage or commercially managed care environment.
Valid Florida RN, LPN, or pharmacy technician (CPhT/RPhT) certification.
2-year college/technical school degree OR 1+ years of related experience/training OR an equivalent combination of education and experience.
Knowledge and understanding of HIPAA regulations, clinical patient care, various diseases and medications, regulatory/accreditation requirements, and pharmacy benefit management.
Strong language skills for effectively reading, analyzing, interpreting, and writing professional journals, technical documents, business reports, and procedure manuals.
Effective verbal/written communication and presentation skills for engaging with managers, clients, and the public.
General math skills (addition, subtraction, multiplication, division, fractions, decimals, ratios, bar graphs, etc.).
High-level reasoning, problem-solving, and clinical research skills.
Proficiency in Microsoft Office, internal database software, and document/statistic production.
Ability to perform the physical duties of the role, including frequently reaching, using hands/fingers/arms, bending, climbing stairs, and crouching.
Ability to pass a background check and drug screening test.

Responsibilities

Overseeing the regulatory and accreditation requirements related to the pharmacy benefit.
Conducting utilization management reviews for physician-administered and specialty medications covered under the medical benefit.
Ensuring requests are reviewed in accordance with evidence-based clinical criteria, benefit requirements, and applicable regulatory guidelines.
Collaborating closely with internal clinical teams, providers, and delegated pharmacy benefit partners to promote quality, compliance, and effective medication management for CHP members.
Ensuring that all activities comply with regulations.
Maintaining departmental files.
Participating in timely data validation for internal and external audits.
Providing oversight for pharmacy benefit manager delegated functions such as formulary administration and coverage determinations.