Pharmacy Benefit Services Specialist - Health Plans Pharmacy
CHRISTUS System Office
No Travel Applicable
CHRISTUS Irving Corporate Health Plan Administration Office
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Pharmacy Benefit Services Specialist - Health Plans Pharmacy Job in Irving
The Pharmacy Benefit Services Specialist job supports the clinical pharmacy department of the health plan (CHRISTUS Health Plan) by ensuring business needs are met in regard to formulary management, Pharmacy Benefit Management (PBM) oversight, pharmaceutical regulatory filings, and pharmaceutical benefits design. Works as part of the pharmacy benefit team to implement and maintain pharmacy benefits and programs, and identify and resolve technical, operational, and vendor problems by performing oversight of pharmacy functions by the PBM. Maintains regulatory filings and website content.
- Performs maintenance and updates of pharmacy program data including formularies and website content.
- Becomes an expert in CHRISTUS Health Plan’s pharmacy program data.
- Performs rejected claim reviews and coverage determination oversight.
- Performs call center report oversight and select sample calls for listening to ensure regulatory requirements are met.
- Reviews adherence report and selects members that should be monitored.
- Ensures processes, policies and procedures are efficient and compliant with regulatory requirements.
- Provides subject matter expertise on Medicare, Health Insurance Exchange, and DoD regulations and guidelines applicable to pharmacy processes.
- Supports internal and external pharmaceutical audits.
- Maintain complete confidentiality of company related business.
- Documents and mitigates formulary related process and compliance opportunities
- Coordinate the effective resolution of Pharmacy Benefits administration problems with the appropriate Sales/Marketing, Member Service, and Complaints, Appeals, and Grievances Representative.
- Effectively helps manage relationship with internal partners and PBM vendors.
- Network and partner with all internal and external stakeholders to effectively plan project timeframes and deliverables.
- Creates documented processes and training materials.
- Assist PBM and other internal staff with responding to inquiries.
- Communicate pharmacy-related written, digital, and telephone inquiries with the pertinent department that sent the original inquiry, i.e. Complaints, Appeals, and Grievances (CAG), Member Services, or Case Management.
- Communicate with PBM to resolve claims and coverage issues.
- Evaluate problems, take appropriate action to correct situations and interface with the appropriate area for correction.
- Performs other duties as assigned or requested.
- Must have a High School diploma or GED completed
- Minimum two (2) years of experience as a certified technician
- Knowledge of applicable state, federal, and third-party regulations
- Minimum three (3) years of full-time experience in pharmacy operations in a managed care setting (e.g., health plan, PBM) preferred
- Knowledge of NCQA, HEDIS, Medicaid, Medicare and Federal programs preferred
- Current Certified Pharmacy Tech National Certification
- Current Texas Board of Pharmacy Certified Technician License
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