Specialist, Pharmacy Operations (Medicaid/ PBM experience)
About The Position
JOB DESCRIPTION Job SummaryProvides support for pharmacy delegated service activities. Responsible for implementation of new products/services and existing business management. Contributes to overarching pharmacy strategy of optimization of medication related health care outcomes, and quality cost-effective member care. Essential Job Duties Supports designated lines of business surveillance and oversight of delegated functions. Analyzes and interprets data to identify erroneous execution of the pharmacy benefit by the Pharmacy Benefit Manager (PBM). Reviews daily inventory of “outliers” and remediates as required. Reviews protocols for accuracy and compliance including: claims, network, digital, etc. Supports internal/external pharmacy audits. Monitors state and federal landscape for new delegated pharmacy opportunities. Collaborates with cross-functional partners to implement new pharmacy products and services and support existing business. Develops and maintains requirements, user stories, test scenarios and test cases. Supports testing execution and defect management. Reviews and interprets member eligibility, claim history, and pharmacy benefit information using the PBM claims software to provide information to both internal and external clients. Serves as PBM and internal liaison for real-time support on pharmacy benefit interpretation or issues. Identifies and assists to remediate gaps and/or deficiencies in current processes, tools, reports and dashboards. Develops and maintains pharmacy related job aids, policies and process documents.
Requirements
- At least 1 year experience in a pharmacy or Pharmacy Benefit Manager (PBM) environment, or equivalent combination of relevant education and experience.
- Strong data analysis skills and attention to detail.
- Strong organizational and problem-solving skills.
- Ability to multitask and demonstrate results oriented work.
- Excellent verbal and written communication skills
- Microsoft Office suite (including Excel), and applicable software program(s) proficiency.
Nice To Haves
- Certified Pharmacy Technician (CPhT).
- Experience in a managed care Pharmacy Benefit Manager (PBM) environment.
- Managed care Medicaid/Marketplace/Medicare experience.
Responsibilities
- Supports designated lines of business surveillance and oversight of delegated functions.
- Analyzes and interprets data to identify erroneous execution of the pharmacy benefit by the Pharmacy Benefit Manager (PBM).
- Reviews daily inventory of “outliers” and remediates as required.
- Reviews protocols for accuracy and compliance including: claims, network, digital, etc.
- Supports internal/external pharmacy audits.
- Monitors state and federal landscape for new delegated pharmacy opportunities.
- Collaborates with cross-functional partners to implement new pharmacy products and services and support existing business.
- Develops and maintains requirements, user stories, test scenarios and test cases.
- Supports testing execution and defect management.
- Reviews and interprets member eligibility, claim history, and pharmacy benefit information using the PBM claims software to provide information to both internal and external clients.
- Serves as PBM and internal liaison for real-time support on pharmacy benefit interpretation or issues.
- Identifies and assists to remediate gaps and/or deficiencies in current processes, tools, reports and dashboards.
- Develops and maintains pharmacy related job aids, policies and process documents.
Benefits
- Molina Healthcare offers a competitive benefits and compensation package.
- Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
