pharmacy benefit manager specialist

Paratek Pharmaceuticals

<div>Position Title: Pharmacy Experience Associate

Department: Commercial - Market Access
Reports To (title): Associate Director Field Reimbursement and Patient Services

Location: Remote - Texas
<ul><li>Exempt Non-Exempt
</li></ul>We are looking for resourceful, collaborative, passionate and purposeful professionals who want to be part of a fast-moving, entrepreneurial environment, where transformational patient solutions are developed!

Summary of Position:
The Pharmacy Experience Associate (PEx) interacts with both internal and external individuals to compliantly support patient access and affordability challenges. This individual has a strong understanding of the variety of patient services that are available and will work efficiently with Healthcare Professionals (HCPs) and pharmacies to support questions related to prescription fulfillment. The incumbent will assess training and education needs of Prescribers, medical office staff, and Pharmacists to support the accurate submission and fulfillment of future prescriptions for the appropriate patient. This individual understands patient access and payer related challenges as well as the complexity of the pharmacy and prescription process. The Pharmacy Experience Associate escalates more complicated cases to the Field Reimbursement and Patient Services Team. They work with a sense of urgency while focused on clear and succinct communication with all parties involved.

This role will be part of the Paratek Market Access team and will report to the Executive Director, Trade Relations, and Patient Services.

Position Responsibilities:
<ul><li>Utilizing data insights, identify prescriptions that are delayed or stalled and take appropriate action.</li>
<li>Establish, develop, and maintain working relationships with regional network specialty pharmacies, their leadership, and staff.</li>
<li>Inform pharmacists and their staff on patient access and affordability programs that could be beneficial to patients.</li>
<li>Work with HCPs to support complete, accurate and timely prescription submissions to Network specialty pharmacies or health plans, to minimize delay in therapy.</li>
<li>Serve as a Network Specialty Pharmacy partner within assigned geography and communicate with stakeholders in a timely manner.</li>
</ul><ul><li>Maintain a strong working relationship with sales and sales leadership.</li>
<li>Assist the Field Reimbursement and Patient Services Team in identifying opportunities for continuous process improvements through root cause analysis and identifying ongoing training needs.</li>
<li>Conduct needs assessment and provides appropriate education for HCPs (i.e., CoverMyMeds, Prior Authorization (PA) process, pharmacy process).</li>
<li>Coordinate cases with patient support service program representatives (HUB) to ensure patient and physician needs are being addressed in a timely manner.</li>
<li>Educate physician office staff on the use of patient assistance programs and call center support services, including web-based provider programs.</li>
<li>Attend POAs and Regional conference calls, providing education, training, and feedback on the positioning of our network pharmacies and the current market access environment, to ensure a clear path for HCP and the patient.</li>
<li>Provide timely information on patient access to the National Account Directors so they are informed and up to date on pharmacy claims and PA process for PBMs and payers.</li>
<li>Collaborate with the Field Reimbursement and Patient Services Team on patient cases that need additional support and training activities with network pharmacies.</li>
<li>Maintain the highest level of ethical obligations and ensure that all activities are complied with applicable laws and regulations.</li>
<li>When called on for business travel manage personal travel schedule and travel arrangements.</li>
<li>Prepare and submit appropriate expense reports in a timely fashion.</li>
</ul>
Candidate Requirements:
<ul>
<li>Bachelor&rsquo;s degree preferred or Licensed / Certified Pharmacy Technician with at least 5+ years of experience; including work with a Pharmacy Benefit Manager, Health Plan, or healthcare provider&rsquo;s office, managing the prescription fulfillment process.</li>
<li>Demonstrated working knowledge of pharmacy benefit design (Commercial, Medicare Part D, Medicaid, and prior authorization processes)</li>
</ul><ul><li>Experience working with pharmacies and/or office-based physician practices preferred.</li>
<li>Understand and comply with HIPAA rules and regulations related to patient privacy.</li>
<li>Demonstrated ability to thrive in a dynamic, fast-paced environment with date sensitive deadlines. Identifying issues quickly and provide solutions.</li>
<li>Strong interpersonal skills and the ability to develop strong working relationships and work collaboratively across cross-functional teams.</li>
<li>Ability to deliver presentations with small and large groups.</li>
<li>Strong written and oral communication skills; and excellent planning and organizational skills.</li>
<li>Demonstrates strong attention to detail.</li>
<li>Ability to work with data and quickly analyze trends and take appropriate action.</li>
<li>Ability to work independently and within a team.</li>
</ul>
Additional Information:
<ul>
<li>Technology needs: Microsoft Office</li>
<li>Travel requirements (%): The average travel for this position is &lt;10% with some variation based upon the time of year and demands of the business imperatives. The travel requirements will vary based on the geography and account responsibilities for this position.</li></ul></div>

Pharmacy Experience Associate (Texas)

<div>
 
 Position Title: Pharmacy Experience Associate
 
 
 
 
 Department: Commercial - Market Access
 
 
 
 
 Reports To (title): Associate Director Field Reimbursement and Patient Services
 
 
 
 
 Location: Remote - Carolinas (Charlotte preferred)
 
 
 
 ☒ Exempt ☐ Non-Exempt
 
 
 We are looking for resourceful, collaborative, passionate and purposeful professionals who want to be part of a fast-moving, entrepreneurial environment, where transformational patient solutions are developed!
 
 
 
 Summary of Position:
 
 
 
 The Pharmacy Experience Associate (PEx) interacts with both internal and external individuals to compliantly support patient access and affordability challenges. This individual has a strong understanding of the variety of patient services that are available and will work efficiently with Healthcare Professionals (HCPs) and pharmacies to support questions related to prescription fulfillment. The incumbent will assess training and education needs of Prescribers, medical office staff, and Pharmacists to support the accurate submission and fulfillment of future prescriptions for the appropriate patient. This individual understands patient access and payer related challenges as well as the complexity of the pharmacy and prescription process. The Pharmacy Experience Associate escalates more complicated cases to the Field Reimbursement and Patient Services Team. They work with a sense of urgency while focused on clear and succinct communication with all parties involved.
 
 
 This role will be part of the Paratek Market Access team and will report to the Executive Director, Trade Relations, and Patient Services.
 
 
 
 Position Responsibilities:
 
 
 
 <ul>
 <li>
 Utilizing data insights, identify prescriptions that are delayed or stalled and take appropriate action.
 </li>
 <li>
 Establish, develop, and maintain working relationships with regional network specialty pharmacies, their leadership, and staff.
 </li>
 <li>
 Inform pharmacists and their staff on patient access and affordability programs that could be beneficial to patients.
 </li>
 <li>
 Work with HCPs to support complete, accurate and timely prescription submissions to Network specialty pharmacies or health plans, to minimize delay in therapy.
 </li>
 <li>
 Serve as a Network Specialty Pharmacy partner within assigned geography and communicate with stakeholders in a timely manner.
 </li>
 <li>
 Maintain a strong working relationship with sales and sales leadership.
 </li>
 <li>
 Assist the Field Reimbursement and Patient Services Team in identifying opportunities for continuous process improvements through root cause analysis and identifying ongoing training needs.
 </li>
 <li>
 Conduct needs assessment and provides appropriate education for HCPs (i.e., CoverMyMeds, Prior Authorization (PA) process, pharmacy process).
 </li>
 <li>
 Coordinate cases with patient support service program representatives (HUB) to ensure patient and physician needs are being addressed in a timely manner.
 </li>
 <li>
 Educate physician office staff on the use of patient assistance programs and call center support services, including web-based provider programs.
 </li>
 <li>
 Attend POAs and Regional conference calls, providing education, training, and feedback on the positioning of our network pharmacies and the current market access environment, to ensure a clear path for HCP and the patient.
 </li>
 <li>
 Provide timely information on patient access to the National Account Directors so they are informed and up to date on pharmacy claims and PA process for PBMs and payers.
 </li>
 <li>
 Collaborate with the Field Reimbursement and Patient Services Team on patient cases that need additional support and training activities with network pharmacies.
 </li>
 <li>
 Maintain the highest level of ethical obligations and ensure that all activities are complied with applicable laws and regulations.
 </li>
 <li>
 When called on for business travel manage personal travel schedule and travel arrangements.
 </li>
 <li>
 Prepare and submit appropriate expense reports in a timely fashion.
 
 
 </li>
 </ul>
 
 Candidate Requirements:
 
 
 
 <ul>
 <li>
 Bachelor's degree preferred or Licensed / Certified Pharmacy Technician with at least 5+ years of experience; including work with a Pharmacy Benefit Manager, Health Plan, or healthcare provider's office, managing the prescription fulfillment process.
 </li>
 <li>
 Demonstrated working knowledge of pharmacy benefit design (Commercial, Medicare Part D, Medicaid, and prior authorization processes)
 </li>
 <li>
 Experience working with pharmacies and/or office-based physician practices preferred.
 </li>
 <li>
 Understand and comply with HIPAA rules and regulations related to patient privacy.
 </li>
 <li>
 Demonstrated ability to thrive in a dynamic, fast-paced environment with date sensitive deadlines. Identifying issues quickly and provide solutions.
 </li>
 <li>
 Strong interpersonal skills and the ability to develop strong working relationships and work collaboratively across cross-functional teams.
 </li>
 <li>
 Ability to deliver presentations with small and large groups.
 </li>
 <li>
 Strong written and oral communication skills; and excellent planning and organizational skills.
 </li>
 <li>
 Demonstrates strong attention to detail.
 </li>
 <li>
 Ability to work with data and quickly analyze trends and take appropriate action.
 </li>
 <li>
 Ability to work independently and within a team.
 
 
 </li>
 </ul>
 
 Additional Information:
 
 
 
 <li>
 Technology needs: Microsoft Office
 </li>
 Travel requirements (%): The average travel for this position is &lt;10% with some variation based upon the time of year and demands of the business imperatives. The travel requirements will vary based on the geography and account responsibilities for this position.
</div>

Pharmacy Experience Associate (Carolinas)

<div>Position Title: Pharmacy Experience Associate

Department: Commercial - Market Access
Reports To (title): Associate Director Field Reimbursement and Patient Services

Location: Remote - Carolinas (Charlotte preferred)
<ul><li>Exempt Non-Exempt
</li></ul>We are looking for resourceful, collaborative, passionate and purposeful professionals who want to be part of a fast-moving, entrepreneurial environment, where transformational patient solutions are developed!

Summary of Position:
The Pharmacy Experience Associate (PEx) interacts with both internal and external individuals to compliantly support patient access and affordability challenges. This individual has a strong understanding of the variety of patient services that are available and will work efficiently with Healthcare Professionals (HCPs) and pharmacies to support questions related to prescription fulfillment. The incumbent will assess training and education needs of Prescribers, medical office staff, and Pharmacists to support the accurate submission and fulfillment of future prescriptions for the appropriate patient. This individual understands patient access and payer related challenges as well as the complexity of the pharmacy and prescription process. The Pharmacy Experience Associate escalates more complicated cases to the Field Reimbursement and Patient Services Team. They work with a sense of urgency while focused on clear and succinct communication with all parties involved.

This role will be part of the Paratek Market Access team and will report to the Executive Director, Trade Relations, and Patient Services.

Position Responsibilities:
<ul><li>Utilizing data insights, identify prescriptions that are delayed or stalled and take appropriate action.</li>
<li>Establish, develop, and maintain working relationships with regional network specialty pharmacies, their leadership, and staff.</li>
<li>Inform pharmacists and their staff on patient access and affordability programs that could be beneficial to patients.</li>
<li>Work with HCPs to support complete, accurate and timely prescription submissions to Network specialty pharmacies or health plans, to minimize delay in therapy.</li>
<li>Serve as a Network Specialty Pharmacy partner within assigned geography and communicate with stakeholders in a timely manner.</li>
</ul><ul><li>Maintain a strong working relationship with sales and sales leadership.</li>
<li>Assist the Field Reimbursement and Patient Services Team in identifying opportunities for continuous process improvements through root cause analysis and identifying ongoing training needs.</li>
<li>Conduct needs assessment and provides appropriate education for HCPs (i.e., CoverMyMeds, Prior Authorization (PA) process, pharmacy process).</li>
<li>Coordinate cases with patient support service program representatives (HUB) to ensure patient and physician needs are being addressed in a timely manner.</li>
<li>Educate physician office staff on the use of patient assistance programs and call center support services, including web-based provider programs.</li>
<li>Attend POAs and Regional conference calls, providing education, training, and feedback on the positioning of our network pharmacies and the current market access environment, to ensure a clear path for HCP and the patient.</li>
<li>Provide timely information on patient access to the National Account Directors so they are informed and up to date on pharmacy claims and PA process for PBMs and payers.</li>
<li>Collaborate with the Field Reimbursement and Patient Services Team on patient cases that need additional support and training activities with network pharmacies.</li>
<li>Maintain the highest level of ethical obligations and ensure that all activities are complied with applicable laws and regulations.</li>
<li>When called on for business travel manage personal travel schedule and travel arrangements.</li>
<li>Prepare and submit appropriate expense reports in a timely fashion.</li>
</ul>
Candidate Requirements:
<ul>
<li>Bachelor&rsquo;s degree preferred or Licensed / Certified Pharmacy Technician with at least 5+ years of experience; including work with a Pharmacy Benefit Manager, Health Plan, or healthcare provider&rsquo;s office, managing the prescription fulfillment process.</li>
<li>Demonstrated working knowledge of pharmacy benefit design (Commercial, Medicare Part D, Medicaid, and prior authorization processes)</li>
</ul><ul><li>Experience working with pharmacies and/or office-based physician practices preferred.</li>
<li>Understand and comply with HIPAA rules and regulations related to patient privacy.</li>
<li>Demonstrated ability to thrive in a dynamic, fast-paced environment with date sensitive deadlines. Identifying issues quickly and provide solutions.</li>
<li>Strong interpersonal skills and the ability to develop strong working relationships and work collaboratively across cross-functional teams.</li>
<li>Ability to deliver presentations with small and large groups.</li>
<li>Strong written and oral communication skills; and excellent planning and organizational skills.</li>
<li>Demonstrates strong attention to detail.</li>
<li>Ability to work with data and quickly analyze trends and take appropriate action.</li>
<li>Ability to work independently and within a team.</li>
</ul>
Additional Information:
<ul>
<li>Technology needs: Microsoft Office</li>
<li>Travel requirements (%): The average travel for this position is &lt;10% with some variation based upon the time of year and demands of the business imperatives. The travel requirements will vary based on the geography and account responsibilities for this position.</li></ul></div>

Community Health Choice

Job Overview Under the direction of the Manager, Managed Care Pharmacy Operation, the Pharmacy Program Specialist II supports the operational needs of the pharmacy team by managing prior authorization processes, coordinating communication between members and providers, and addressing issues with the Pharmacy Benefit Manager (PBM). The role requires a strong understanding of medical benefit drug coverage and adherence to regulatory timelines. The specialist also contributes to reporting, monitoring delegated PBM functions, and promoting member adherence, while delivering a high level of customer service.QUALIFICATIONS:Required Preferred Education/Specialized Training/Licensure: Bachelor&rsquo;s degree in healthcare field, or in business administration Actively registered with the Texas State Board of Pharmacy as a certified pharmacy technicianWork Experience (Years and Area): Minimum Three (3) years&rsquo; experience with a Health Plan or PBM in related functions Strong experience with prior drug authorization process in a Health Plan or PBMPay: $23.46 - $29.32 per hourBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: Hybrid remote in Houston, TX 77081

Pharmacy Program Specialist II

Ventegra Inc. A California Benefit Corporation

The Benefit Preservation Specialist is responsible for program solutions in order to extend the health benefits of members, including but not limited to, patient assistant program(s) for medication coverage, pharmaceutical coupon programs and ancillary claims adjudication. The Benefit Preservation Specialist also plays a key role in helping members maximize the value of their pharmacy benefits through the coordination and management of manufacturer copay card programs, patient assistance programs, and benefit preservation strategies. This individual acts as a liaison between members, providers, and internal departments to ensure financial resources are applied accurately and efficiently to support member access to medications.Schedule: This role follows a Pacific Standard Time (PST) schedule, regardless of the employee&rsquo;s physical location. Candidates may reside in other time zones but must be available to work one of the following schedules in PST hours:<ul><li>7:30 a.m. &ndash; 4:00 p.m. HST (Monday&ndash;Friday)</li><li>9:00 a.m. &ndash; 5:30 p.m. HST (Monday&ndash;Friday)</li><li>9:30 a.m. &ndash; 6:00 p.m. HST (Monday&ndash;Friday)</li></ul>Candidates must be able to work from 6:00am - 12:00pm HST for the first few weeks of training. Duties:<ul><li>Maintain database of existing coupons and patient assistant programs involved</li><li>Assess and identify appropriate program(s) for members based on needs</li><li>Coordinate programs between pharmacy, members and plans as needed</li><li>Effectively communicate between the Customer Care Department and Prior Authorization personnel for seamless and efficient member service</li><li>Ensure compliance with all applicable laws and regulations</li><li>Continually evaluates processes and training materials for effectiveness and efficiency of the programs</li><li>Perform QA analysis to ensure appropriate monetary values are being applied to both claim and benefit as applicable</li><li>Develop and document policy and procedures</li><li>Implement new plans to the program</li><li>Term plans as they unenroll from the program</li><li>Assist with member communication as needed when changes to plans are made (i.e. biosimilar conversions)</li><li>Maintain and correct member deductible and maximum out of pocket accumulators as relates to coupon programs</li><li>Assist in other projects as assigned by management</li></ul>Skills/Qualifications:<ul><li>Excellent communications skills (oral, written and interpersonal)</li><li>Analytic skills</li><li>Pharmacy Tech certified required</li><li>Demonstrated ability to work well in a team environment</li><li>Demonstrated ability to provide exceptional customer service</li></ul>Education and Experience:<ul><li>High school diploma or equivalent</li><li>2+ years of experience in pharmacy benefit management, healthcare administration, or a related field.</li><li>Knowledge of pharmacy claim adjudication processes and benefit plan design, a plus</li><li>Familiarity with manufacturer copay and patient assistance programs, a plus.</li></ul>About Ventegra: Ventegra is the premier, fully transparent Medical Benefits Manager (MBM) offering Pharmacy Services Administration products and services to help manage healthcare for businesses and consumers. Ventegra is committed to seeking innovative ways to channel our resources for a greater impact to improve the lives of others. Ventegra represents payors, providers, patients and government programs.Job Type: Full-timePay: From $18.00 per hourBenefits:<ul><li>401(k)</li><li>401(k) matching</li><li>Dental insurance</li><li>Employee assistance program</li><li>Health insurance</li><li>Health savings account</li><li>Life insurance</li><li>Paid time off</li><li>Professional development assistance</li><li>Retirement plan</li><li>Vision insurance</li></ul>Application Question(s):<ul><li>Are you able to work a schedule of 7:30am-4:00pm, 9:00am-5:30pm, or 9:30am-6:00pm Hawaii Standard Time?</li><li>Are you able to work a training schedule of 6:00am-12:00pm Hawaii Standard Time ?</li></ul>Experience:<ul><li>Pharmacy technician: 1 year (Preferred)</li><li>Pharmacy Benefit: 1 year (Required)</li></ul>License/Certification:<ul><li>Pharmacy Technician Certification (Preferred)</li></ul>Work Location: Remote

Member Benefit Preservation Specialist

GEHA Health

<div>
 
 Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care.
 
 
 
 
 
 G.E.H.A has one mission: To empower federal workers to be healthy and well.
 
 
 
 
 
 
 
 
 The Utilization Management and Oversight Pharmacist will assist with corporate strategy to achieve better healthcare value and lower cost for our members, while ensuring quality pharmaceutical care for our members, in an effort to make our insurance product more competitive and support growth.
 
 
 
 
 
 The Utilization Management and Oversight Pharmacist widely supports the operation of the pharmacy benefit and its functional teams. The position will be responsible for the following:
 
 
 &bull; Insuring proper medication utilization among our membership
 
 
 &bull; Developing and maintaining customized prior authorization criteria
 
 
 &bull; Developing and maintaining custom benefit exclusions
 
 
 &bull; Completing enterprise-wide drug information requests
 
 
 &bull; Preparing pharmacy recommendations for the pharmacy leadership
 
 
 &bull; Proposing and implementing pharmacy benefit design changes
 
 
 &bull; Increasing member outcomes by collaborating with other departments within the enterprise
 
 
 &bull; Supporting utilization review strategies and risk management related to the utilization of pharmaceuticals
 
 
 &bull; Collaborating with staff responsible for day-to-day activities of the Pharmacy Department
 
 
 &bull; Coordinating with other departments within the organization (ie: Care Management, SIU, Product, Marketing) to support strategic and operational objectives of the Pharmacy Department.
 
 
 
 
 
 
 
 SKILLS
 
 
 
 
 
 
 SKILLS
 
 
 
 
 
 Clinical Pharmacist; Utilization Management and Oversight
 
 
 
 Duties and Responsibilities
 
 <ul>
 <li>
 Responsible for day-to-day management of clinical pharmacy needs within the department including controlled substance monitoring, high risk member monitoring, high dollar claim monitoring and customized prior authorization criteria and exclusion management
 </li>
 <li>
 Collaborates with plan level associates (including Pharmacy Vice President and Managers, Care Management, Medical Directors, Quality Management and others as necessary) to identify members requiring clinical pharmacy intervention(s)
 </li>
 <li>
 Independently completes accurate and comprehensive medication reviews and performs the corresponding member, care management, and other outreach as necessary
 </li>
 <li>
 Researches and synthesizes detailed clinical data related to pharmaceuticals to identify opportunities for improving quality or overall cost
 </li>
 <li>
 Serves as pharmacy SME on projects and clinical care activities; supports internal business partners such as Product Development, Care and Case Managers, Special Investigations, and Medical Operations
 </li>
 <li>
 Leads, manages and/or supports medical cost management, utilization management and medication management initiatives, projects and related activities
 </li>
 <li>
 Assists in pharmacy medication exception reviews coming in from multiple sources including OPM, PBM, GEHA Executive Leadership, GEHA Appeals Department, etc.
 </li>
 <li>
 Assists member-facing pharmacy staff by providing medication therapy evaluations, recommendations and next steps for members and providers
 </li>
 <li>
 Works in partnership with the Vice President and Clinical Manager of Pharmacy to plan, implement and maintain clinical programs and services
 </li>
 <li>
 Serves as clinical pharmacy resource and drug information specialist to medical, pharmacy, nursing and SIU staff
 </li>
 <li>
 Reviews medical policy drafts and provides recommendations for change to medical policy staff
 </li>
 <li>
 Assists member-facing pharmacy staff in assembling responses for prescriber/member appeals, grievances, disputes, inquiries and reconsiderations within established time periods
 </li>
 <li>
 Supports clinical quality and corporate HEDIS measures by providing pharmacy perspective and developing strategies to achieve goals
 </li>
 <li>
 Serves on internal committees and/or workgroups and completes special projects as assigned
 </li>
 </ul>
 
 
 
 
 Job Qualifications
 
 
 
 Education
 
 
 <ul>
 <li>
 Doctor of Pharmacy (PharmD) degree from an ACPE-accredited School of Pharmacy
 </li>
 <li>
 Postgraduate training/residency required
 </li>
 </ul>
 
 
 Experience
 
 
 <ul>
 <li>
 Candidate must be licensed, or eligible for licensure, within the state of Missouri
 </li>
 <li>
 Candidate must have 5 years of experience, or completion of a PGY-1/PGY-2 residency with a managed care and/or drug information focus preferred
 </li>
 <li>
 Experience should include managed care
 </li>
 <li>
 Minimum three (3) years of managed care experience that has involved interaction with patients, providers and other healthcare professionals
 </li>
 <li>
 Knowledge of managed care pharmacy principles including medical exception reviews, formulary management, and utilization review required
 </li>
 <li>
 Candidate should possess an extensive understanding of evidence-based pharmacy practice, including disease specific therapies along with knowledge and ability to search medical literature for supporting clinical references
 </li>
 </ul>
 
 
 Skills/Certifications
 
 
 <ul>
 <li>
 Must contribute to the One Team value of GEHA, be organized and have the ability to handle multiple projects
 </li>
 <li>
 Exemplary interpersonal, communication and organizational skills
 </li>
 <li>
 Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles, and accountability
 </li>
 <li>
 Proficient in Microsoft Office (Outlook, Word, Excel, Vizio and PowerPoint)
 </li>
 <li>
 Solid understanding of government scope (FEHB, OPM, FDA, ACA, USPSTF) required
 </li>
 <li>
 Competency in compendia navigation and research
 </li>
 </ul>
 
 
 
 
 Work-at-home requirements
 
 <ul>
 <li>
 Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
 </li>
 <li>
 A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
 </li>
 <li>
 Latency (ping) response time lower than 80 ms
 </li>
 <li>
 Hotspots, satellite and wireless internet service is NOT allowed for this role.
 </li>
 <li>
 A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
 </li>
 </ul>
 
 
 
 
 How we value you
 
 <ul>
 <li>
 Competitive pay/salary ranges
 </li>
 <li>
 Incentive plan
 </li>
 <li>
 Health/Vision/Dental benefits effective day one
 </li>
 <li>
 401(k) retirement plan: company match &ndash; dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
 </li>
 <li>
 Robust employee well-being program
 </li>
 <li>
 Paid Time Off
 </li>
 <li>
 Personal Community Enrichment Time
 </li>
 <li>
 Company-provided Basic Life and AD&amp;D
 </li>
 <li>
 Company-provided Short-Term &amp; Long-Term Disability
 </li>
 <li>
 Tuition Assistance Program
 </li>
 </ul>
 
 
 
 
 While this is a remote opportunity, at this time G.E.H.A does not hire employees from U.S. territories or the following states: Alaska, Hawaii, California, Washington, Oregon, Colorado, Wyoming, Montana, New York, Connecticut, Vermont, Pennsylvania, Maine.
 
 
 
 
 
 Please note that the salary information is a general guideline only. G.E.H.A considers factors such as (but not limited to) scope and responsibilities of the position, candidate&rsquo;s work experience, education/training, key skills, internal peer equity, as well as, market and business considerations when extending an offer.
 
 
 
 
 
 The hiring range for this position is $118,092 - $149,394 USD. At G.E.H.A, the current maximum salary for this role is $166,468 USD. While initial compensation may vary based on experience and qualifications, there is a path to work toward this top rate through performance and continued growth within the organization.
 
 
 
 
 
 G.E.H.A is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. G.E.H.A will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. We are committed to creating an inclusive environment for all employees.
 
 
 
 
 
 G.E.H.A is headquartered in Lee's Summit, Missouri, in the Kansas City area. We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.
 
</div>

Clinical Pharmacist, Utilization Management and Oversight

EmblemHealth

<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. 
</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. 
</li><li>
Responsible for creating and maintaining plan/benefit design documentation to support internal and external requirements 
</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. 
</li><li>
Assess all requests for new/ changes to plan benefit information to ensure compatibility with PBM claim adjudication logic. 
</li><li>
Submit accurate and complete requests to the PBM for new and changing benefit plan designs. 
</li><li>
Test pharmacy benefit plan designs for accuracy and alignment with business requirements. 
</li><li>
Serve as liaison to PBM to troubleshoot and resolve benefit-related questions/ issues, researching plan/benefit design options and requirements. 
</li><li>
Participate in PBM implementation meetings as required. 
</li><li>
Review and approve PBM benefit set up requirements. 
</li><li>
Perform claim testing to ensure accurate claim adjudication. 
</li><li>
Work with the pharmacy clinical team to implement formulary updates in the claim adjudication system. 
</li><li>
Participate in the research and resolution of claims adjudication-related discrepancies, errors, and problems. 
</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. 
</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. 
</li><li>
Recommend streamlined work processes and systems that impact plan/ benefit design to create efficiency and quality outcomes. 
</li><li>
Maintain acceptable and appropriate quality levels and production SLA response time. 
</li><li>
Perform other projects and duties as assigned</li></ul>
<div><div>Qualifications</div><ul><li>
Bachelor&rsquo;s degree. 
</li><li>
Pharmacy Technician Certification (Required) 
</li><li>
Additional years of related experience may be considered in lieu of degree (Required) 
</li><li>
Ability to perform in office environment with extended periods of sitting, using telephone, and viewing computer screens (Required) 
</li><li>
Ability to prioritize tasks daily and trouble shoot urgent customer issues to successful completion (Required) 
</li><li>
Advanced knowledge of MS Office - Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc. (Required) 
</li><li>
Exceptional problem solving, analytical, interpersonal and communication skills to resolve issues within Operations (Required) 
</li><li>
Professionally skilled in verbal and written communication (Required) 
</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>Additional Information
<ul><li>Requisition ID: 1000003022</li>
<li>Hiring Range: $56,160-$99,360</li></ul></div></div>

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