- Review daily rejected claim report.
- Contact providers/pharmacies informing formulary alternatives when available and/or how to submit Prior Authorization requests and follow up on the cases when necessary.
- Assist dispensing pharmacies with claim issues.
- Analysis and identify inappropriately paid and denied claims that have financial implications both for the pharmacy budget and prevention of financial actions from CMS.
- Act as pharmacy liaison between the clinical pharmacy department and other internal departments. Answer or re-direct internal and external questions related to pharmacy; provide supportive research and analysis as needed and follow through to resolution.
- Review transition fill a report to ensure transition fills are appropriate and assist provider with formulary alternative switch.
- Generate and distribute reports to the Pharmacy Management team and other programs as needed. Upload PBM reports to the Pharmacy SharePoint sites and keeps the document organized and complete.
- Provide support to the pharmacy team on different clinical programs, which includes care coordination with pharmacy/providers, record keeping/tracking, and reporting.
- Perform additional functions as needed for the operations of the Pharmacy department.
- High School Diploma or equivalent required; Pharmacy Technician Certification is preferred; Bachelor's degree preferred but not required.
- 2-5 years of Retail Pharmacy, Health Plan, and/ or PBM (pharmacy benefit manager) experience preferred. Demonstrates knowledge in the field of pharmacy.
- Expert level proficiency with Microsoft applications, including use of Excel, Word, and PowerPoint. Able to create reports and manipulate data sets.
- Self-motivated, with demonstrated ability to work independently with minimal supervision.
- Ability to communicate clearly and effectively, both verbally and in writing.
- High level of integrity as demonstrated by 1) appropriate treatment of confidential information, 2) adherence to policies, procedures, rules, and regulations, 3) professional conduct in dealing with persons internal and external to the organization, and 4) sensitivity towards target population.
- Multi-lingual a plus.
- Follow all applicable government regulations including HIPAA.
- Performs other related duties as required.
- Relates to and communicates effectively with staff, participants, and families.
- Incorporates a customer service approach to problem-solving and all operations.
- Adheres to all Human Resources (HR) and Staff Development policies and procedures, including facility and department orientation and mandatory training and education.
- Standing - Duration of up to 6 hours a day.
- Sitting/Stationary Positions - Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
- Lifting/Push/Pull - Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.
- Bending/Squatting - Have to be able to safely bend or squat to perform the essential functions under the scope of the job.
- Stairs/Steps/Walking/Climbing - Must be able to safely maneuver stairs, climb up/down, and walk to access work areas.
- Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)
- Sight/Visual Requirements - Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.
- Audio Hearing and Motor Skills (Language) Requirements - Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
- Cognitive Ability - Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.
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Pharmacy Specialist - New York City, United States - CenterLight Health System
Description
JOB PURPOSE:
The Pharmacy Specialist should have a good understanding of Centers for Medicare and Medicaid Services (CMS) federal regulations and New York State Medicaid regulations related to the pharmacy benefit.
The OM function has financial implications for the detection of claims processing issues and has a direct impact if a participant is unable to obtain his or her medications under the required guidelines.
The Pharmacy Specialist is a vital part of the pharmacy team, and coordinates care for our participants to ensure medication access.
JOB RESPONSIBILITIES:
Schedule: 8:30 AM - 5:30 PM
QUALIFICATIONS:
Education:
Other:
Individuals must be able to sustain certain physical requirements essential to the job.
This includes, but is not limited to:
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information.
We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.
Salary Range (Min-Max):
$55, $60,000.00
