Sr. Health Plan Pharmacist

UnitedHealth Group•Pearland, TX

7d•$112,700 - $193,200•Onsite

About The Position

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together. This position is responsible for assisting the Health Plan Pharmacy Services department in all areas including but not limited to: Pharmacy Operations, Clinical Pharmacy Quality Initiatives, Pharmacy oversight and audits and Health plan reporting. Part D activities related to formulary management, coverage decisions, pharmacy benefit management, pharmacy claims processing and monitoring functions that help ensure the department is in compliance with CMS standards. This position will also assist with administrative clinical pharmacy activities deemed necessary for Kelsey-Seybold Clinic and drug trend management

Requirements

Pharm D. degree
Completion of an accredited ASHP/AMCP Managed Care Pharmacy Residency Program (PGY1) OR 2 years HMO 3rd party managed care experience OR 2 years operational pharmacy benefit experience
Current and Active Pharmacy License
Texas State Board of Pharmacy Registered Pharmacist
Solid communication skills with personnel, members, and healthcare providers for delegation, training, claims approval, complaint resolution, medication recommendations, and education
Ability to write reports, create policies, procedures, work guides, and training documents
Excellent alpha/numeric data entry skills with minimal errors
Proficiency in Microsoft Word and Excel
Multitasking, problem-solving, and analytical skills
Detail-oriented with good verbal and written communication, interpersonal skills, professional appearance, and ability to work in a fast-paced environment
High stress tolerance to ensure accurate pharmacy benefit administration approved by CMS

Nice To Haves

Medicare Part D experience
Auditing experience
Customer Service experience
Proficient in RxClaim or other claims adjudication systems and EPIC
Professional Appearance

Responsibilities

Maintain and monitor Medicare Part D formularies, including updates, HPMS submissions, adjudication system coding, member materials, and notifications
Align formulary and drug coverage decisions with clinical guidelines and regulations by conducting drug utilization reviews and monitoring industry trends
Review prescribing trends to ensure alignment with health plan formularies and cost-effective treatment strategies
Conduct and validate formulary and transition coding, testing, and disruption analysis; resolve errors with PBM and internal departments
Ensure formulary decisions support company goals and collaborate with other departments to align with business strategy
Ensure timely, accurate, and compliant coverage determinations, reimbursements, and appeals; validate CDR reportable data
Resolve decision-making errors with PBM and internal departments; serve as the CDR subject matter expert
Conduct benefit testing and review production claims to ensure compliance with CMS requirements
Review retrospective eligibility adjustments for payment accuracy.
Administer new regulatory requirements and resolve adjudication errors with PBM and internal departments
Implement CMS Drug Management Program activities, monitor at-risk beneficiaries, and ensure compliance with OIG requirements
Review FWA reports, perform audits, investigate potential FWA cases, and report to CMS as needed
Understand CMS regulations and requirements, monitor communications and legislative developments, and analyze their impact
Communicate internal monitoring activities with the compliance team and support leadership in CMS reporting and audits
Oversee PBM and vendor performance to ensure contract and CMS requirements are met
Track, reconcile, and report FDR performance, identify deficiencies, and ensure timely communication of tasks and expectations
Update educational materials for KCA and KSC teams, communicate formulary updates, and implement health plan medication initiatives
Provide administrative and clinical support for committees and attend meetings; document and follow up on action items
Respond to inquiries from pharmacies, members, and representatives regarding pharmacy claims and benefit questions
Conduct clinical reviews of medications, identify cost-effective alternatives, and provide patient counseling and medication reconciliation
Develop accurate marketing documents and Part D Model Materials, including formularies, directories, EOBs, and coverage criteria
Review Medicare Prescription Payment Plan materials and prepare AEP training documents for member services and marketing teams
Develop and maintain Part D policies, procedures, workflows, and action plans
Support technical staff, pharmacy residency program, and intern education and training
Provide administrative and clinical support for special projects and adhere to pharmacy laws