Job Description
Job Description
Position Summary:The Pharmacy services Specialist will assist the Clinical Services staff (pharmacists and technicians) in all aspects of pharmacy operations and services including Medicare part D oversight, coverage determination and re-determination (appeal) process, workflow management and direct communication to all applicable parties (internal and external). The pharmacy specialist will also work with the compliance department to perform frequent audits and provide exceptional customer service (internal and external) within applicable departmental and local and federal regulatory guidelines.
Essential Duties and Responsibilities
- Conducts Eligibility Reconciliation, coverage determination and redetermination based on specific CMS required guidelines.
- Leads and support the creation, maintenance, and organization of SOP's, P&P, and business process flows Acts as the subject matter expert (SME) for pharmacy benefit design, products and programs as it relates to CMS and other regulatory entities.
- Interacts with pharmacy benefit manager (PBM) to support the implementation of new pharmacy products or services and oversee all regulatory reporting requirements.
- Conducts operational training participate in compliance and quality initiatives as it relates to the pharmacy department.
- Participate the delegation oversight and conduct frequent audits to ensure compliance with regulatory entities such as CMS, NCQA, URAC.
- Intervenes, as necessary, to resolve member or provider issues with network pharmacies to ensure members receive medications in a timely manner.
- Communicate, collaborate and cooperate with internal and external stakeholders.
- Adheres to all Compliance/Program Integrity requirements.
- Complies with HIPAA Regulations Ensures safe care to patients, staff and visitors; adheres to all Apex Health Solutions policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff
- Other duties as assigned.
Qualifications:To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
In addition to the qualifications below, the qualified candidate must have:
- Knowledge of pharmacy operations and drug information.
- Customer service abilities including effective listening skills.
- Ability to meet strict deadlines and deliver project results within a specific timeframe.
- Demonstrates strong project managements skills with the ability to analyze issues and problem-solve working accurately with attention to detail within specified time periods.
- Knowledgeable and compliant with all relevant laws, rules regulations and accreditation standards and requirement.
- Ability to set priorities and solve problems and respond to emergency requests.
- Proficiency in word, excel & power point Excellent verbal and written communication skills
- Working knowledge of PBM system or experience working in a health plan or managed care setting.
- Must be a team player.
Competencies: To perform the job successfully, an individual should demonstrate the following:
Adaptability - Adapts to changes in the work environment. Manages competing demands. Accepts criticism and feedback. Changes approach or method to best fit the situation.
Communication - Expresses ideas and thoughts verbally. Expresses ideas and thoughts in written form. Exhibits good listening and comprehension. Keeps others adequately informed. Selects and uses appropriate communication methods.
Dependability - Responds to requests for service and assistance. Follows instructions, responds to management direction. Takes responsibility for own actions. Commits to doing the best job possible. Keeps commitments. Meets attendance and punctuality guidelines.
Quality - Demonstrates accuracy and thoroughness. Displays commitment to excellence. Looks for ways to improve and promote quality. Applies feedback to improve performance. Monitors own work to ensure quality.
Quantity - Meets productivity standards. Completes work in timely manner. Strives to increase productivity. Works quickly. Achieves established goals.
Teamwork - Balances team and individual responsibilities. Exhibits objectivity and openness to others' views. Gives and welcomes feedback. Contributes to building a positive team spirit. Puts success of team above own interests.
Education/Experience:
Required:
· High School Diploma or Equivalent required.
· Two (2) to five (5) years of experience as a pharmacy tech in a retail or community pharmacy setting, health plan, HMO and/or PBM setting.
OR
· Prior population health experience or other work experience in an equivalent background such as Medicare Part D program.
Certificates and Licenses: Current, unrestricted Certified Pharmacy Technician (CPhT) with active Registration with applicable State Board of Pharmacy upon hire required.
Supervisory Responsibilities: None
Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually quiet.
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.