Pharmacy Programs Specialist

Clover Health

7h•$53,800 - $70,000•Remote

About The Position

The Clinical Pharmacy team is an innovative team that utilizes a member-centric approach to provide comprehensive medication management services. The Pharmacy Programs Specialist will work to support Medicare quality metrics, medication management initiatives, and maintain Centers for Medicare and Medicaid Services compliance standards. In this role, you would perform validation of claim adjudication ensuring appropriate access to care and support telephonic outreach for plan members, providers and other healthcare professionals. In addition, document activity and maintain electronic medical records while providing the highest quality healthcare and service to plan members and other internal and external partners.

Requirements

At least three (3) years of experience working in pharmacy, managed care organization, medical office or in a hospital setting.
Fluent in English and Spanish, both orally and in writing.
Understanding of managed care.
PC skills in Windows-based applications.
Excellent written and oral communication skills.
Able to work Eastern Time (ET) hours; candidates in this time zone, preferred.

Nice To Haves

National Certification (CPhT) Pharmacy Technician License (preferred).

Responsibilities

Create, manage, and respond to cases and/or escalate to Clinical Pharmacists on the Team.
Contribute to improving Part D Star measures by resolving root causes of medication management problems and taking appropriate action to provide recommendations based on profile review or patient interview.
Represent for the Pharmacy team and participate in cross-functional team meetings
Collect and present data and trends from Pharmacy Benefits Manager (PBM) delegated functions to cross-functional operational workgroups to propose process improvements
Deliver on cross-functional team initiatives and ad-hoc projects that impact Clover business goals
Provide guidance to internal and external teams in regards to pharmacy clinical and regulatory workflows, policies and processes
Serve as a liaison between PBM Account Management Team and Clover Health and escalate any questions that need PBM involvement for resolution.
Organize pharmacy team meetings with internal and external partners.
Think critically and problem solve to prioritize and work more efficiently
Improve team’s capacity and knowledge
Distribute work to peers and strategize completion of quality assurance projects that require short turn around times
Provide recommendations on and deliver Part D content knowledge updates on internal knowledge base directory annually and ad-hoc
Lead educational training for cross functional teams on Part D knowledge and vendor platforms
Participate in call center quality assurance reviews
Perform strategic work to increase MTMP Star measure
Navigate and use tools and platforms required for task/queue-based work
Show curiosity as to how work impacts the business and how that work is generated
Complete a larger volume of assigned tasks with increasing focus on program/project-based opportunities and work and serve as a resource to others
Communicate with the pharmacy leadership team in a timely manner when issues arise.
File, review, and validate reports to ensure compliance with Medicare guidelines.
Gather data and generate reports to improve clinical pharmacy quality metrics.
Participate in training and orientation of new team members, as needed.
Execute other job duties as assigned.