Pharmacy Benefit Analyst Technician
JOB
Summary: The Pharmacy Benefit analysts conduct oversight activities of all PBM vendor functions ensuring pharmacy benefits for all lines of Health Choice business (Medicare, Medicaid, Health Exchange, etc.) are functioning consistent with regulatory requirements and health plan member care objectives. The Pharmacy Benefit Analyst is also responsible for working closely with health plan pharmacists assisting with member management as well as developing and maintaining pharmacy benefit policies, procedures and desktops that accurately represent internal and external pharmacy benefit processes as well as train Health Choice staff on the presence and execution of these documented processes.
Job Responsibility: Assure accurate administration of pharmacy benefits by PBM
Update and enforce pharmacy benefit management policies and procedures in accordance with accreditation, state and federal guidelines and requirements
oCreate and maintain desktop processes related to the management and oversight of PBM functions
oSupport internal (Health Choice) and external (CMS, AHCCCS) pharmacy audits
Serve as point person for PBM functions during implementations and ongoing benefits administration
oCoordinate project teams to create clear definition of required PBM functionality and ensure PBM execution of functionality.
oWork closely with pharmacist and pharmacy technician staff
oTest new functionality to ensure desired outputs
Establash monitors to ensure maximum PBM performance in areas including, but not limited to:
oPrescription claims processing consistent with formulary and formulary rules (e.g. work reject reports)
oAccurate member cost share application (tier copays/ coinsurances, LIS copays, formulary) based on benefit (Medicare, Medicaid, etc.)
oData submission
oMedicare specific functions:
CMS Part D reports
Member Explanation of Benefits
New enrollee transitions
Price file submission(s) to CMS
Acumen and/or CMS audits or requests for information
Pharmacy coordination of benefits
Website posting formulary documents and drug criteria
oMedicaid specific functions:
Pharmacy benefit administration per AHCCCS Contractor Operations Manual (ACOM), AHCCCS Medical Policy Manual (AMPM) and UDOH Provider Manual
Encounter file 'pend resolution assistance
Pharmacy coordination of benefits
Member transitions
Collaborate with Medicaid and Medicare pharmacists and Pharmacy Director on PBM functions and deliverables
Collaborate with Medicaid and Medicare pharmacists on project deliverables related to key operational processes and member case research
Conduct research of Medicare and Medicaid requirements in response to health plan staff or member inquiries
Communicate and interact with the Medicare and AHCCCS administration and resources as appropriate
Perform daily PBM oversight functions working closely with Medicaid and Medicare pharmacists to resolve and prevent issues and assist with appropriate member access to care.
Serve as point person for PBM and health plan pharmacy benefit administration projects.
oAssist with research and resolution of identified pharmacy benefit discrepancies
oResearch specific member issues as needed
oAssist with resolution of prescription claim issues identified by Health Choice staff
oAssist with resolution of pharmacy provider issues (Pharmacy Network including Mail and Specialty providers)
oSign off on PBM COFs under direction of pharmacists
Assist pharmacists with pharmacy benefit projects related to member access to care (e.g. member transitions, etc.)
Conduct and assist with pharmacy prior authorizations and member specific authorizations.
Review the accuracy of prescription drug information on Health Choice websites and other member and provider resources
Conduct quality control activities related to PBM benefit changes as appropriate
Educate and train staff on pharmacy benefit requirements, processes and key projects directed by the Medicaid or Medicare pharmacists.
As required to meet regulatory and accreditation requirements as well as ensure efficiency and effectiveness of staff activities related to pharmacy benefit services duties may include, but are not limited to:
Participation in meetings both external and internal
Development and presentation of training materials
Creation of effective communication mechanisms to keep staff up to date with pharmacy benefit requirements and functions
Education of staff on PBM processes to assist with pharmacy benefit operations
Other responsibilities and duties that may be assigned by management.
Expected Outcomes:
Organized and assessable documentation of policies, procedures and desktops
Project prioritization and outcomes meet the needs of business initiatives and projects
Managed and accurate prescription claims processing
Accurate and timely CMS and State Medicaid data submissions and reporting
Timely resolution of PDE rejects and encounter pends preventing loss costs and sanctions
Appropriate communications with government program resources
Work closely with health plan pharmacists to ensure appropriate provision of pharmacy benefits to members.
PBM action log is accurate and thoroughly describe action item status
Organized, assessable and appropriate distributed desktops as appropriate
Completed pharmacy benefit changes and enhancements within set time parameters
Managed and accurate prescription claims processing
Timely resolution PBM pharmacy benefit administration or member claims processing issues
Conduct member pharmacy prior authorizations and member specific authorizations consistent with pharmacy staff policies and procedures.
Education and training documents will be retained and distributed as appropriate
Education session attendance will be documented, and retained.
Education and training will be conducted timely
Documentation will be retained when required
Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment while still being valued for your individual strengths Health Choice is the place for you.
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
Professional Competencies (knowledge, skills, and abilities):
Knowledge
Knowledge of prescription claims processing and PBM vendor functions and services
Knowledge of Medicaid and Medicare pharmacy benefit requirements
General knowledge of AHCCCS, Medicaid and Medicare and resources for information
Skills
Excellent computer skills (MS Word, Excel. PowerPoint)
Proficient in PBM claims processing and Prior Authorization systems
Excellent communication (verbal and written) skills required
Organizational skills required
Attention to detail
Presentation skills preferred
Abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Ability to work independently
Ability to work well and communicate with all levels of staff and management
Ability to manage multiple projects and prioritize work tasks to adhere to deadlines and identified time frames
Education: High school diploma or GED equivalent
Bachelor's degree preferred
Experience:
At least three (3) years of managed care pharmacy and/ or pharmacy benefit management experience required
At least one (1) year of licensed pharmacy technician experience
At least two (1) year managing projects and working with a team
At least one (1) year of Policy & Procedure as well as desktop process writing necessary
Experience in performance improvement functions preferred
Certification and License: Certified Pharmacy Technician preferred
. Apply now!Estimated Salary: $20 to $28 per hour based on qualifications.
Summary: The Pharmacy Benefit analysts conduct oversight activities of all PBM vendor functions ensuring pharmacy benefits for all lines of Health Choice business (Medicare, Medicaid, Health Exchange, etc.) are functioning consistent with regulatory requirements and health plan member care objectives. The Pharmacy Benefit Analyst is also responsible for working closely with health plan pharmacists assisting with member management as well as developing and maintaining pharmacy benefit policies, procedures and desktops that accurately represent internal and external pharmacy benefit processes as well as train Health Choice staff on the presence and execution of these documented processes.
Job Responsibility: Assure accurate administration of pharmacy benefits by PBM
Update and enforce pharmacy benefit management policies and procedures in accordance with accreditation, state and federal guidelines and requirements
oCreate and maintain desktop processes related to the management and oversight of PBM functions
oSupport internal (Health Choice) and external (CMS, AHCCCS) pharmacy audits
Serve as point person for PBM functions during implementations and ongoing benefits administration
oCoordinate project teams to create clear definition of required PBM functionality and ensure PBM execution of functionality.
oWork closely with pharmacist and pharmacy technician staff
oTest new functionality to ensure desired outputs
Establash monitors to ensure maximum PBM performance in areas including, but not limited to:
oPrescription claims processing consistent with formulary and formulary rules (e.g. work reject reports)
oAccurate member cost share application (tier copays/ coinsurances, LIS copays, formulary) based on benefit (Medicare, Medicaid, etc.)
oData submission
oMedicare specific functions:
CMS Part D reports
Member Explanation of Benefits
New enrollee transitions
Price file submission(s) to CMS
Acumen and/or CMS audits or requests for information
Pharmacy coordination of benefits
Website posting formulary documents and drug criteria
oMedicaid specific functions:
Pharmacy benefit administration per AHCCCS Contractor Operations Manual (ACOM), AHCCCS Medical Policy Manual (AMPM) and UDOH Provider Manual
Encounter file 'pend resolution assistance
Pharmacy coordination of benefits
Member transitions
Collaborate with Medicaid and Medicare pharmacists and Pharmacy Director on PBM functions and deliverables
Collaborate with Medicaid and Medicare pharmacists on project deliverables related to key operational processes and member case research
Conduct research of Medicare and Medicaid requirements in response to health plan staff or member inquiries
Communicate and interact with the Medicare and AHCCCS administration and resources as appropriate
Perform daily PBM oversight functions working closely with Medicaid and Medicare pharmacists to resolve and prevent issues and assist with appropriate member access to care.
Serve as point person for PBM and health plan pharmacy benefit administration projects.
oAssist with research and resolution of identified pharmacy benefit discrepancies
oResearch specific member issues as needed
oAssist with resolution of prescription claim issues identified by Health Choice staff
oAssist with resolution of pharmacy provider issues (Pharmacy Network including Mail and Specialty providers)
oSign off on PBM COFs under direction of pharmacists
Assist pharmacists with pharmacy benefit projects related to member access to care (e.g. member transitions, etc.)
Conduct and assist with pharmacy prior authorizations and member specific authorizations.
Review the accuracy of prescription drug information on Health Choice websites and other member and provider resources
Conduct quality control activities related to PBM benefit changes as appropriate
Educate and train staff on pharmacy benefit requirements, processes and key projects directed by the Medicaid or Medicare pharmacists.
As required to meet regulatory and accreditation requirements as well as ensure efficiency and effectiveness of staff activities related to pharmacy benefit services duties may include, but are not limited to:
Participation in meetings both external and internal
Development and presentation of training materials
Creation of effective communication mechanisms to keep staff up to date with pharmacy benefit requirements and functions
Education of staff on PBM processes to assist with pharmacy benefit operations
Other responsibilities and duties that may be assigned by management.
Expected Outcomes:
Organized and assessable documentation of policies, procedures and desktops
Project prioritization and outcomes meet the needs of business initiatives and projects
Managed and accurate prescription claims processing
Accurate and timely CMS and State Medicaid data submissions and reporting
Timely resolution of PDE rejects and encounter pends preventing loss costs and sanctions
Appropriate communications with government program resources
Work closely with health plan pharmacists to ensure appropriate provision of pharmacy benefits to members.
PBM action log is accurate and thoroughly describe action item status
Organized, assessable and appropriate distributed desktops as appropriate
Completed pharmacy benefit changes and enhancements within set time parameters
Managed and accurate prescription claims processing
Timely resolution PBM pharmacy benefit administration or member claims processing issues
Conduct member pharmacy prior authorizations and member specific authorizations consistent with pharmacy staff policies and procedures.
Education and training documents will be retained and distributed as appropriate
Education session attendance will be documented, and retained.
Education and training will be conducted timely
Documentation will be retained when required
Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment while still being valued for your individual strengths Health Choice is the place for you.
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
Professional Competencies (knowledge, skills, and abilities):
Knowledge
Knowledge of prescription claims processing and PBM vendor functions and services
Knowledge of Medicaid and Medicare pharmacy benefit requirements
General knowledge of AHCCCS, Medicaid and Medicare and resources for information
Skills
Excellent computer skills (MS Word, Excel. PowerPoint)
Proficient in PBM claims processing and Prior Authorization systems
Excellent communication (verbal and written) skills required
Organizational skills required
Attention to detail
Presentation skills preferred
Abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Ability to work independently
Ability to work well and communicate with all levels of staff and management
Ability to manage multiple projects and prioritize work tasks to adhere to deadlines and identified time frames
Education: High school diploma or GED equivalent
Bachelor's degree preferred
Experience:
At least three (3) years of managed care pharmacy and/ or pharmacy benefit management experience required
At least one (1) year of licensed pharmacy technician experience
At least two (1) year managing projects and working with a team
At least one (1) year of Policy & Procedure as well as desktop process writing necessary
Experience in performance improvement functions preferred
Certification and License: Certified Pharmacy Technician preferred
. Apply now!Estimated Salary: $20 to $28 per hour based on qualifications.
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