Pharmacy Quality and Medication Adherence Outreach Advisor

Martin's Point Health Care•Portland, ME

About The Position

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. Position Summary The Pharmacy Quality Advisor will support focused efforts and initiatives to drive improvement for our Medicare beneficiaries. These efforts will be focused on Pharmacy related to HEDIS and CMS Star measures. The specialist will conduct member outreach, monitor adherence data, and coordinate with internal and external partners to support quality improvement initiatives. This role will also collaborate closely with pharmacists, providers, and care management teams to improve patient outcomes, reduce hospitalizations, and enhance quality performance measures.

Requirements

High school diploma or equivalent required.
2+ years’ experience in operations, data analysis, or program development related to health care
2+ years’ experience Managed Care, Health Plan, and Part D benefits/program experience
Knowledge of Medicare Part D regulations, health plan operations, Pharmacy Benefit Management operations, and best practices preferred
Knowledge of pharmacy operations, medications, and chronic disease management
Windows Based Computer skills: data entry and word processing ability
Working knowledge of Microsoft Office products including Word, Excel and PowerPoint
Demonstrated telephone etiquette and positive interpersonal skills
Strong communication, empathy, and problem-solving skills
Strong interpersonal skills and ability to collaborate with internal and external clients
Excellent customer services skills
Superior written and verbal communication skills
Ability to be flexible with changing priorities and work in a fast-paced environment
Applies proactive and innovative solutions to improve process effectiveness when appropriate
Solid analytical skills
Ability to reconcile financial reports and data
Strong mathematical ability
Knowledge of PBM third party billing, pharmacy claims processing, and pharmacy data management
Proficiency in Microsoft Office applications (Word, Excel, PowerPoint)
Strong organizational skills
Self-motivated with ability to manage, prioritize and complete multiple projects in a timely fashion with limited supervision
Takes appropriate initiative while soliciting input/advice
Ability to handle confidential and sensitive information in a discreet and professional manner

Nice To Haves

Associate’s or bachelor’s degree in healthcare-related field preferred.
Certified Pharmacy Technician (CPhT), Medical Assistant, or similar clinical experience preferred
Prior experience or exposure to pharmacy or managed care pharmacy preferred
Experience in quality management or compliance roles strongly preferred
Experience with Medicare Star Ratings and knowledge of adherence-related measures preferred.

Responsibilities

Performs routine audits of pharmacy operations, prior authorization requests, and appeals processes to ensure accuracy and compliance with federal, state, and accreditation regulations (e.g., NCQA).
Adheres to HIPAA, DoD, CMS, and all state, federal, departmental, and organizational policies to ensure patient privacy and compliance.
Analyzes claims and utilization data to monitor performance metrics and track key quality indicators (e.g., HEDIS, Medicare Stars measures).
Conducts strategic outreach to members to identify barriers to adherence and assist with resolution.
Tracks, trends, presents and reports common adherence barriers and member feedback to inform quality improvement efforts to health plan leaders (for example, quality and CM) and delivery system
Leads quality improvement projects and initiatives using data analysis and root cause analysis to identify and resolve process problems and enhance efficiency and quality.
Partners with clinical leaders of the health plan and delivery system to develop, implement, and execute effective medication adherence initiatives and other quality improvement efforts.
Develops and maintain standard operating procedures (SOPs), work instructions, and training materials.
Develops and manage library of pharmacy related materials.
Serves as a liaison between providers, pharmacists, patients, and community pharmacies.
Collaborates with cross-functional teams (clinical, IT, operations) on quality measures, health plan performance, and alignment of clinical and operational goals.
Serves as a resource for formulary, prior authorizations, and cost-sharing inquiries.