Qureos Mentor

EmblemHealth

<div></div><div><div>Summary of Job</div><div>
Serve as dedicated strategic resource to support Pharmacy product offerings and teams: support Internal Product Leads for pharmacy components, including the City of New York Account Team and Client, Medicare Product, Exchange/Essential Plan Product, Medicaid/CHP Product, and Fully Insured and ASO Commercial Client and Product Teams. Build, maintain, and organize documentation of existing Product Offerings, options for the products and recommendations for future enhancements or changes. Provide excellent internal and external customer service for clients, client account teams, and Product P&amp;L Leads. Collaborate on the development and lifecycle of pharmacy products, ensuring they meet market needs, achieve sales targets, and contribute to company success. Oversee all stages of product development lifecycle from initiation to completion including from initial concept to post-launch activities, adapting strategies as needed and ensuring on-time, on-budget, and compliant delivery. Conduct and aggregate thorough market research to identify opportunities, analyze trends, and understand client/member needs and trends.</div><div>
Responsibilities</div><ul><li>
Collaborate with various teams, including Clinical Pharmacy, Pharmacy Operations, Product Leads, Account Management, Sales, Marketing, Regulatory, and Legal, to ensure alignment and successful product development, management, promotion and ongoing execution.</li><li>
Develop project plans for all aspects of assigned projects; manage all project activities; establish and lead cross functional project teams and status meetings; monitor and manage project scope, budget, forecast, resources, and deliverables within established timelines; maintain up-to-the-minute project action plans and serve as a resource to stakeholders. Provide timely, comprehensive project status reports, including budgets and timelines.</li><li>
Proactively identify significant project risks, develop mitigation strategies, escalate to leadership, and implement approved mitigation steps.</li><li>
Work to understand client, prospect, member, and market needs, analyzing competitors and their products.</li><li>
Collaborate with senior/departmental management and client groups/LOBs to evaluate ideas and incorporate product feedback during strategic development.</li><li>
Communicate product plans, progress, and performance to stakeholders.</li><li>
Strategic Planning: evaluate market trends, define product requirements, and manage product lifecycles.</li><li>
Product Development &amp; Launch: contribute to product formulation, designing packaging, and leading launch strategies.</li><li>
Manage product launches, develop marketing and promotional materials, and support sales efforts.</li><li>
Regulatory Compliance: ensure all products adhere to regulatory standards, including packaging, labeling, and clinical trial documentation.</li><li>
Effectively communicate pharmacy product information to internal and external stakeholders.</li><li>
Manufacturing Oversight: work with technical teams and third-party manufacturers to ensure supply availability.</li><li>
Monitor product performance, build and maintain reports, analyze data, and make recommendations for improvements to optimize product success.</li></ul>
<div><div>Qualifications</div><ul><li>
Bachelor's degree in business, healthcare or related field.</li><li>
5 &ndash; 8+ years of relevant, professional work experience (Required)</li><li>
Strong understanding of pharmaceutical market dynamics and regulations (Required)</li><li>
Proven experience in pharmaceutical project management, regulatory affairs, or product development (Required)</li><li>
Expertise in GMP (Good Manufacturing Practices), GCP (Good Clinical Practices), and regulatory requirements (e.g., FDA, EMA) (Required)</li><li>
Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required)</li><li>
Strong leadership, project management, risk management, and strategic thinking capabilities (Required)</li><li>
Ability to work effectively in a cross-functional team environment (Required)</li><li>
Proficiency in market research and analysis (Required)</li><li>
Experience in product development and lifecycle management (Required)</li></ul>
</div><div><p>Additional Information
</p><ul><li>Requisition ID: 1000003107</li>
<li>Hiring Range: $77,760-$149,040</li></ul></div></div>

Pharmacy Product Project Manager - Hybrid/Remote

<div></div><div><div>Summary of Job</div><div>
Support eligibility and benefits configuration and deployment, including collaboration with pharmacy benefits manager (PBM) and Cognizant, formulary teams, for configuration. Responsible for Quality Assurance and Testing for operations and implementations. Coordinate and manage the pharmacy plan/ benefit design implementation process in partnership with PBM to ensure the accuracy and timeliness of members&rsquo; pharmacy benefit administration for superior member experience.</div><div>
Responsibilities</div><ul><li>
Maintain in-depth understanding of and ability to create and maintain plan/benefit design rules and limitations to include: Adjudication rules, Clinical rules, Payment rules, and Plan/group management.<br>
</li><li>
Partner with Sales and Product teams, assist in developing pharmacy benefit plan designs, meeting client requests, Health Plan strategic/ business parameters and all regulatory and other oversight agencies&rsquo; requirements.<br>
</li><li>
Responsible for creating and maintaining plan/benefit design documentation to support internal and external requirements<br>
</li><li>
Lead communication and coordination between Health Plan and PBM for receipt of required information for claims adjudication system set up, reporting and claim adjudication process.<br>
</li><li>
Assess all requests for new/ changes to plan benefit information to ensure compatibility with PBM claim adjudication logic.<br>
</li><li>
Submit accurate and complete requests to the PBM for new and changing benefit plan designs.<br>
</li><li>
Test pharmacy benefit plan designs for accuracy and alignment with business requirements.<br>
</li><li>
Serve as liaison to PBM to troubleshoot and resolve benefit-related questions/ issues, researching plan/benefit design options and requirements.<br>
</li><li>
Participate in PBM implementation meetings as required.<br>
</li><li>
Review and approve PBM benefit set up requirements.<br>
</li><li>
Perform claim testing to ensure accurate claim adjudication.<br>
</li><li>
Work with the pharmacy clinical team to implement formulary updates in the claim adjudication system.<br>
</li><li>
Participate in the research and resolution of claims adjudication-related discrepancies, errors, and problems.<br>
</li><li>
Acts as a resource to operational areas in support of the pharmacy claims adjudication process and responding to issues related to plan/ benefit design.<br>
</li><li>
Conduct quarterly audits of pharmacy benefit configurations to ensure alignment with plan design, regulatory requirements, and accurate claim adjudication across all lines of business.<br>
</li><li>
Recommend streamlined work processes and systems that impact plan/ benefit design to create efficiency and quality outcomes.<br>
</li><li>
Maintain acceptable and appropriate quality levels and production SLA response time.<br>
</li><li>
Perform other projects and duties as assigned</li></ul>
<div><div>Qualifications</div><ul><li>
Bachelor&rsquo;s degree.<br>
</li><li>
Pharmacy Technician Certification (Required)<br>
</li><li>
Additional years of related experience may be considered in lieu of degree (Required)<br>
</li><li>
Ability to perform in office environment with extended periods of sitting, using telephone, and viewing computer screens (Required)<br>
</li><li>
Ability to prioritize tasks daily and trouble shoot urgent customer issues to successful completion (Required)<br>
</li><li>
Advanced knowledge of MS Office - Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc. (Required)<br>
</li><li>
Exceptional problem solving, analytical, interpersonal and communication skills to resolve issues within Operations (Required)<br>
</li><li>
Professionally skilled in verbal and written communication (Required)<br>
</li><li>
Meticulous organization skills, with the ability to multi-task, and ability to make sound decisions in a timely and independent manner (Required)</li></ul>
</div><div><p>Additional Information
</p><ul><li>Requisition ID: 1000003022</li>
<li>Hiring Range: $56,160-$99,360</li></ul></div></div>

Pharmacy Benefits Operations Specialist - Remote

<div></div><div><div>Summary of Job</div><div>
Perform provider and member outreach to reconcile member records and validate data entry to support continuous quality improvement in Healthcare Effectiveness Data and Information Set (HEDIS) rates and STAR measures for the enterprise. Facilitate provider and member outreach supporting the MTM, OMW, and Medication Adherence quality measures to ensure member receipt of important clinical services to improve member health outcomes. Daily telephonic outreach to secure appointments with pharmacists and/or vendors to close gaps in care. Support efficient medical record retrieval for HEDIS medical record review and HEDIS supplemental data collection activities. Track calls for all lines of business related to the MTM, OMW, and Medication Adherence quality measures, reporting weekly completion statistics. Produce and process department mailings to members and physicians. Monitor internal mailboxes for department faxes and calls. Collaborate with internal departments in order to administer the MTM, OMW, and Medication Adherence quality measures.</div><div>
Responsibilities</div><ul><li>
Work closely with Clinical Pharmacist(s), Registered Nurses and Data Analyst(s) to prioritize members for outreach who fall in HEDIS measures including but not limited to Medication Adherence and OMW (Osteoporosis Management in Women who had a fracture) and the STAR measure MTM (Medication Therapy Management) Program.<br>
</li><li>
Perform daily telephonic outreach to secure appointments with pharmacists and/or vendors to close gaps in care supporting Enterprise goals.<br>
</li><li>
Perform daily provider and member outreach supporting the MTM, OMW, and Medication Adherence quality measures to ensure member receipt of important clinical services to improve member health outcomes.<br>
</li><li>
Prepare and execute member and provider mailings.<br>
</li><li>
Collaborate with providers and internal departments to ensure the receipt and correct processing of all supplemental data related to HEDIS claims and records and assist in correcting discrepancies.<br>
</li><li>
Maintain high data integrity while adhering to HIPAA standards and protecting patient information.<br>
</li><li>
Perform provider outreach to verify and document member&rsquo;s appropriate medical diagnoses and subsequent treatments both by telephone and in writing.<br>
</li><li>
Coordinate call tracking and provide statistics to stakeholders.<br>
</li><li>
Intake and organize data from other departments while ensuring proper compliance with all CMS regulations, policies and procedures.<br>
</li><li>
Other duties/projects as assigned.</li></ul>
<div><div>Qualifications</div><ul><li>
High School Diploma (Required)<br>
</li><li>
College Degree (Preferred)<br>
</li><li>
Pharmacy Technician License (Preferred)<br>
</li><li>
Minimum of 1 year direct customer service experience in a healthcare setting (Required)<br>
</li><li>
Excellent telephonic and customer service skills (Required)<br>
</li><li>
Experience analyzing data and building action plans based upon data outcomes (Required)<br>
</li><li>
Personal motivation to achieve set goals (Required)<br>
</li><li>
Flexibility and ability to adjust workflow to achieve company goals (Required)<br>
</li><li>
Experience with or knowledge of Electronic Medical Records (Preferred)<br>
</li><li>
Knowledge of or experience with HEDIS, STAR ratings, and/or quality improvement (Preferred)<br>
</li><li>
Experience in a managed care health services environment (Preferred)<br>
</li><li>
Experience in data collection, data entry and analysis (Preferred)<br>
</li><li>
Knowledge of Excel and other analytical tools (Preferred)</li></ul>
</div><div><p>Additional Information
</p><ul><li>Requisition ID: 1000003045</li>
<li>Hiring Range: $39,960-$70,200</li></ul></div></div>

Quality Outreach Specialist - Remote

Join EmblemHealth and explore 3   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

EmblemHealth

About Company

Pharmacy Product Project Manager - Hybrid/Remote

Pharmacy Benefits Operations Specialist - Remote

Quality Outreach Specialist - Remote