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- Designs and implements processes to support accreditation activities pertaining to pharmacy in order to maintain qualified accreditation status.
- Provides regular formal updates to staff on current applicable accreditation standards, state and federal quality improvement requirements in order to incorporate the most current standards and requirements into staff daily workflow.
- Collaborates with interdepartmental workgroup teams for quality improvement initiatives to improve Healthcare Effectiveness Data and Information Set (HEDIS) standards and five star ratings.
- Assists leadership with developing and implementing metrics and performance targets to assess compliance with Center for Medicare and Medicaid Services (CMS) regulations.
- Adapts existing plans and processes to accommodate new federal/state requirements for government sponsored drug programs and utilization of new technologies to maintain compliance.
- Reviews and updates Pharmacy policy and procedure documents to ensure the department is in compliance with the Center for Medicare and Medicaid Services (CMS), Office of the Commissioner of Insurance (OCI), National Committee for Quality Assurance (NCQA), and any other applicable regulatory guidelines.
- Maintains working knowledge of the various pharmacy documenting systems utilized within the department and monitors accuracy of staff utilization of those documenting systems to ensure operational and security parameters are followed consistently.
- Regular attendance is required in order to carry out the essential functions of the position.
- Reviews and meets ongoing competency requirements of the role to maintain the skills, knowledge and abilities to perform, within scope, role specific functions.
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SHP Pharmacy Quality Assurance - Marshfield, United States - Marshfield Clinic
Description
Come work at a place where innovation and teamwork come together to support the most exciting missions in the worldJob Title:
SHP Pharmacy Quality Assurance - Auditing Specialist (Remote, hybrid or in office)
Cost Center:
SHP-Pharmacy
Scheduled Weekly Hours:
40
Employee Type:
Regular
Work Shift:
Mon-Fri; 8:00 am - 5:00 pm (United States of America)
Job Description:
JOB SUMMARY
The SHP Pharmacy Quality Assurance/Auditing Specialist monitors, performs, and manages quality assurance processes including those supporting compliance to regulatory and accreditation standards.
This role works closely with the Security Health Plan (SHP) compliance team in monitoring regulatory guidelines and investigating instances of fraud, waste, and abuse as it pertains to SHP pharmacy issues and with the SHP quality improvement team in activities and requirements pertaining to National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS), and 5 Star Quality Measures.
Position can be remote or in office.JOB QUALIFICATIONS
EDUCATION
For positions requiring education beyond a high school diploma or equivalent, educational qualifications must be from an institution whose accreditation is recognized by the Council for Higher Education and Accreditation.
Minimum Required:
High school diploma or equivalent. Post-secondary courses in medical terminology, pharmacology and health insurance or managed care.
Preferred/Optional:
None
EXPERIENCE
Minimum Required:
Five years' experience as a pharmacy technician in a retail pharmacy and an HMO pharmacy environment. Expertise in electronic pharmacy claims processing and pharmacy claims processing systems.
Preferred/Optional:
Experience in quality assurance and auditing functions and experience with National Committee for Quality Assurance (NCQA) or Healthcare Effectiveness Data and Information Set (HEDIS) standards.
CERTIFICATIONS/LICENSESThe following licensure(s), certification(s), registration(s), etc., are required for this position. Licenses with restrictions are subject to review to determine if restrictions are substantially related to the position.
Minimum Required:
Certified Pharmacy Technician (CPhT) provided by the Wisconsin Department of Safety and Professional Services (DSPS).
Preferred/Optional:
None
At Marshfield Clinic Health System, we are fully committed to addressing health equity, diversity and inclusion for our employees and providers, our patients, and the communities we serve.
Exclusion From Federal Programs:
Employee may not at any time have been or be excluded from participation in any federally funded program, including Medicare and Medicaid.
This is a condition of employment.Employee must immediately notify his/her manager or the Health System's Compliance Officer if he/she is threatened with exclusion or becomes excluded from any federally funded program.
Marshfield Clinic Health System is an Equal Opportunity/Affirmative Action employer.All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.