Qureos Mentor

Medical Mutual

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 We are seeking candidates who are currently based in Ohio for this role.
 
 
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 Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
 
 
 
 Medicare Pharmacy Coordinator I
 
 
 
 
 
 Job Summary:
 
 
 
 
 Working under general supervision, administers typically more standardized or routine daily operations in compliance with the Medicare Part D (pharmacy) and Medicare Part C (medical drug) benefit programs. Configures, implements, maintains, and services Medicare and Individual pharmacy benefits, with a strong focus on member experience.
 
 
 
 
 Responsibilities:
 
 
 
 
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 Coordinates pharmacy reject review and resolution either directly or forwards/escalates to other departments or PBM. Monitors paid claims for accuracy including for transition supply oversight. Ensures timely communication to members on coverage determination and prescriptions with timeframe restrictions, assesses coverage review accuracy, and triages as needed.
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 Assists in outbound calls to members, providers, and pharmacies to initiate coverage determinations/appeals, prescription refills, and switch members to lower cost therapeutic alternatives based on discussions with providers. Documents all attempts in tracking software.
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 Collaborates with Clinical Intervention Pharmacists on Medicare Stars and other quality initiatives, with a strong focus on member experience. Conducts outreach to Pharmacy Benefit Manager (PBM) for refills, claim reprocessing and to members to provide status of intervention.
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 Tracks and coordinates daily issue/response files with PBM for claim resolution. Outreaches to pharmacy/prescriber as needed.
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 Generates reports from pharmacy system and reviews production metrics. .
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 Supports operational oversight overflow and any additional requests. Responds to Part D and Part B benefit questions, updates tracking documents, and ensures effectuation of claims.
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 Builds and maintains knowledge of new or updated CMS regulations, Coverage Gap Discount, Coverage Determinations and Appeals, Grievances, and Medicare marketing material requirements.
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 Assists in internal and external audits and projects of the Medicare Part D (pharmacy) and Part C (medical drug) programs as needed.
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 Performs other duties as assigned.
 
 
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 Qualifications:
 
 
 
 
 
 Education and Experience:
 
 
 
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 Associate Degree in Business Administration, Healthcare, or related field or equivalent combination of experience, training, and education.
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 4 &ndash; 5 years of experience in a health plan, pharmacy, or PBM operations, which includes exposure to Centers for Medicare &amp; Medicaid Services (CMS) guidelines, preferably Part D.
 
 
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 Professional Certification(s):
 
 
 
 
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 Certified Pharmacy Technician (CPhT) preferred.
 
 
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 Technical Skills And Knowledge:
 
 
 
 
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 Knowledge of CMS guidelines and Medicare Part D (pharmacy).
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 Knowledge of pharmacy claims processing through retail or mail pharmacy.
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 Intermediate Microsoft Office skills (Excel, Word, Power Point).
 
 
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 Medicare Pharmacy Coordinator II
 
 
 
 
 
 Job Summary:
 
 
 
 
 Working under general supervision, administers standardized to moderately complex daily operations in compliance with the Medicare Part D (pharmacy) and Medicare Part C (medical drug) benefit programs. Configures, implements, maintains, and services Medicare and Individual pharmacy benefits, with a strong focus on member experience.
 
 
 
 
 Responsibilities:
 
 
 
 
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 Coordinates pharmacy reject review and resolution either directly or forwards/escalates to other departments or PBM. Monitors paid claims for accuracy including for transition supply oversight. Ensures timely communication to members on Part D coverage determination, all levels of appeal, re-openings (case re-decision) and Part C organization determination, and prescriptions with timeframe restrictions, assesses coverage review accuracy, and triages as needed.
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 Coordinates remediation efforts for Hospice and End Stage Renal Disease (ESRD) processes.
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 Supports Medicare Pharmacy Specialists in the research and review of Part D and Part B inquiries, grievances, and CTMs, updating tracking documents, audit research items, and marketing material reviews.
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 Assists in outbound calls to members, providers, and pharmacies to initiate coverage determinations/appeals, prescription refills, and switch members to lower cost therapeutic alternatives based on discussions with providers. Documents all attempts in tracking software.
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 Collaborates with Clinical Intervention Pharmacists on Medicare Stars and other quality initiatives, with a strong focus on member experience. Conducts outreach to Pharmacy Benefit Manager (PBM) for refills, claim reprocessing and to members to provide status of intervention.
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 Generates reports from pharmacy system and reviews production metrics. Conducts Part D Explanation of Benefits (EOB) audit.
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 Tracks and coordinates daily issue/response files with PBM for claim resolution. Outreaches to pharmacy/prescriber as needed. Supports operational oversight overflow and any additional requests. Responds to Part D and Part B benefit questions, updates tracking documents, and ensures effectuation of claims.
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 Maintains knowledge of new or updated CMS regulations, Coverage Gap Discount, Coverage Determinations and Appeals, Grievances, and Medicare marketing material requirements. Assists in internal and external audits and projects of the Medicare Part D (pharmacy) and Part C (medical drug) programs as needed.
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 Assists more junior level with any oversight process questions.
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 Performs other duties as assigned.
 
 
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 Education And Experience:
 
 
 
 
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 Associate Degree in Business Administration, Healthcare, or related field or equivalent combination of experience, training, and education.
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 1-2 years of experience as a Medicare Pharmacy Coordinator or equivalent 5-6 years of experience in a health plan, pharmacy, or PBM operations, which includes exposure to Centers for Medicare &amp; Medicaid Services (CMS) guidelines, specifically Part D.
 
 
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 Technical Skills And Knowledge:
 
 
 
 
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 Strong knowledge of CMS guidelines and Medicare Part D (pharmacy).
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 Strong knowledge of pharmacy claims processing through retail or mail pharmacy.
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 Intermediate Microsoft Office skills (Excel, Word, Power Point).
 
 
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 A Great Place To Work:
 
 
 
 Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
 
 
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 We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
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 Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
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 On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
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 Discounts at many places in and around town, just for being a Medical Mutual team member.
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 The opportunity to earn cash rewards for shopping with our customers.
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 Business casual attire, including jeans.
 
 
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 Excellent Benefits And Compensation:
 
 
 
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 Employee bonus program.
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 401(k) with company match up to 4% and an additional company contribution.
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 Health Savings Account with a company matching contribution.
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 Excellent medical, dental, vision, life and disability insurance &mdash; insurance is what we do best, and we make affordable coverage for our team a priority.
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 Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
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 Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
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 After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
 
 
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 An Investment In You:
 
 
 
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 Career development programs and classes.
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 Mentoring and coaching to help you advance in your career.
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 Tuition reimbursement up to $5,250 per year, the IRS maximum.
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 Diverse, inclusive and welcoming culture with Business Resource Groups.
 
 
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 About Medical Mutual:
 
 
 
 Medical Mutual&rsquo;s status as a mutual company means we are owned by our policyholders, not stockholders, so we don&rsquo;t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
 
 
 There&rsquo;s a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.
 
 
 We&rsquo;re not just one of the largest health insurance companies based in Ohio, we&rsquo;re also the longest running. Founded in 1934, we&rsquo;re proud of our rich history with the communities where we live and work.
 
 
 
 We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
 
 
 
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Medicare Pharmacy Coordinator

Join Medical Mutual and explore 1   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.

Medical Mutual

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Medicare Pharmacy Coordinator