Pharmacy Services Vendor Specialist

Blue Cross and Blue Shield Association-posted 3 months ago
Philadelphia, PA
Religious, Grantmaking, Civic, Professional, and Similar Organizations
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The Pharmacy Vendor Specialist analyzes data and provides compliance oversight of the pharmacy vendor to ensure processes such as pharmacy claims payment and coverage determinations are compliant. The Pharmacy Vendor Specialist is also responsible to lead or participate in meetings as well internal or external audits.

  • Investigate and provide root cause analysis, impact and issue remediation for compliance issues.
  • Review supporting documentation to ensure that key OMT indicators identifying compliance are met.
  • Provides direction regarding next steps of issue(s) identified such as letter language, Rx authorization overrides, member outreach etc.
  • Provides direction for member resolution which includes but is not limited to reimbursements, letter generation, Rx overrides, Rx Grandfathering etc.
  • Support the daily DPR process to identify adjudication issues and escalate appropriately.
  • Support weekly compliance issue resolutions meeting to ensure closure (Kathy's team, delegation oversight, PBM). Provide direction to PBM on next steps how to address errors or issues (i.e.., reprocessing claims, etc.)
  • Provides final approval to release reprocessed claims (notify PBM).
  • Collect and validate data to support audits. (Internal, NCQA, CMS audit, self-funded).
  • Collect and validate data to support external vendor audit request to comply with format and audit timeframes.
  • Coordinate with the PBM regarding audit requirements, PBM provides data, this role reviews the request against what comes back from PBM. If not accurate, goes back to PBM. If accurate, release the data.
  • Report PBM performance within the performance guarantee process. (monitor for the month the PBM performance guarantee. Track and trend metrics and documentation.
  • Conducts daily coverage determinations timeliness review.
  • Conducts daily coverage determination letter QA to ensure accuracy. (letter generated at PBM and ensuring the compliance oversight of letter).
  • Escalate all findings with recommendations and outlining compliance risks. (looking at report of work from PBM the prior day, verifying the work was accurate and compliant. If not, identify, determine regulations, identify what failed and outline compliance risks)
  • Bachelor's degree or equivalent work experience
  • 3+ Years related work experience
  • Medicare and/or health plan operations experience preferred
  • Audit experience
  • Pharmacy Background preferred
  • Microsoft Word and Excel proficiency
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