Job description

Position Summary: This position is responsible for the day-to-day oversight and handling functions of the Prescription Drug Program (Part D) benefits for Ultimate Health Plans Medicare Advantage members. Areas of responsibility include evaluation, processing and clinical assessment of coverage determinations, oversight of daily rejection, member and provider outreach, grievances and appeals research, direct member reimbursement (DMR).

Essential Duties and Responsibilities

Oversees the clinical decisions of the PBM ensuring clinical criteria meet guidelines and recommends a coverage determination decision on approvals and/or denials when necessary.

Follows up with Member or Providers as needed to obtain or verify additional information and record completeness and accuracy of coverage determination cases.

Communicates with PBM, Pharmacist and/or Members to provide updates and/or resolution of coverage determinations.

Document case detail information to include date and time or receipt, investigation, verbal and written communication, resolution, parties involved in all pertinent internal and PBM systems to ensure data integrity for CMS and NCQA audits.

Ensures timely processing and review of functions to meet CMS and NCQA standards as well as specific company goals.

Ensures prescription coverage provided to eligible members are appropriate based on benefit design and appropriateness of medications for condition are being utilized. (i.e.: formulary management, tier and quantity exceptions, brand limits, etc.)

Collaborate with PBM and internal departments on the implementation of clinical initiatives and strategies that help improve the members’ health, well-being and outcomes.

Responds to requests from member service, and appeals and grievance on any issues relating to the Prescription Drug Program.

Performs additional duties and/or projects as assigned.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.

Design - Demonstrates attention to detail.

Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.

Project Management - Develops project plans; Coordinates projects; Communicates changes and progress; Completes projects on time and budget; Manages project team activities.

Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.

Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Meets commitments.

Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.

Oral Communication - Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.

Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.

Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.

Visionary Leadership - Displays passion and optimism; Inspires respect and trust; Mobilizes others to fulfill the vision; Provides vision and inspiration to peers and subordinates.

Change Management - Develops workable implementation plans; Communicates changes effectively; Builds commitment and overcomes resistance; Prepares and supports those affected by change; Monitors transition and evaluates results.

Delegation - Delegates work assignments; Matches the responsibility to the person; Gives authority to work independently; Sets expectations and monitors delegated activities; Provides recognition for results.

Leadership - Exhibits confidence in self and others; Inspires and motivates others to perform well; Effectively influences actions and opinions of others; Accepts feedback from others; Gives appropriate recognition to others.

Managing People - Includes staff in planning, decision-making, facilitating and process improvement; Takes responsibility for subordinates' activities; Makes self available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Solicits and applies customer feedback (internal and external); Fosters quality focus in others; Improves processes, products and services.; Continually works to improve supervisory skills.

Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.

Business Acumen - Understands business implications of decisions; Displays orientation to profitability; Demonstrates knowledge of market and competition; Aligns work with strategic goals.

Cost Consciousness - Works within approved budget; Develops and implements cost saving measures; Contributes to profits and revenue; Conserves organizational resources.

Diversity - Shows respect and sensitivity for cultural differences; Promotes a harassment-free environment; Builds a diverse workforce.

Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.

Organizational Support - Follows policies and procedures; Supports organization's goals and values; Supports affirmative action and respects diversity.

Judgment - Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.

Motivation - Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles; Measures self against standard of excellence.

Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Sets goals and objectives; Organizes or schedules other people and their tasks; Develops realistic action plans.

Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.

Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.

Quantity - Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly.

Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions; Uses equipment and materials properly.

Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.

Attendance/Punctuality - Is consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.

Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals.; Completes tasks on time or notifies appropriate person with an alternate plan.

Initiative - Seeks increased responsibilities; Asks for and offers help when needed.

Innovation - Meets challenges with resourcefulness; Generates suggestions for improving work.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Supervisory Responsibilities

This job has no direct supervisory responsibility

Qualifications, Education and/or Experience

Bachelor’s degree, Certified Pharmacy Technician Certificate or Degree, or equivalent experience preferred

4 to 6 years of progressive experience in the PBM, Part D Program, Pharmacy Operations and/or Managed Care preferred

Proficient in working with Microsoft Office software, including Microsoft Excel, Power Point, and Word as well as MS Internet Explorer.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually quiet.

Travel

Individuals in this position may be required to travel up to 15% of the time to perform the job functions and should have a valid driver’s license

Job Type: Full-time

Pay: $17.00 - $19.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Physical setting:

• Office

Schedule:

• Monday to Friday
• No weekends

Experience:

• Pharmacy technician experience: 1 year (Preferred)

License/Certification:

• Pharmacy Technician Certification (Required)

Work Location: In person

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