Specialist, Pharmacy Operations (Medicaid/ PBM experience)
About The Position
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
