Medicare Pharmacy Specialist-Paramount Health Job Listing at Medical Mutual in United States of America (Job ID 2400476)

Description

Note, this is a remote opportunity. Eastern Time Zones preferred.

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Responsibilities

Medicare Pharmacy Specialist I

Supports the successful operations and compliant administration of the Medicare Pharmacy (Part D) program. Oversees Pharmacy Benefit Manager (PBM) to meet CMS compliance for all delegated activities. Acts as Subject matter expert (SME) on assigned operational aspects of Part D product and Medical Drug (Part C) program and as a liaison between internal departments and vendors.

·         Supports oversight and monitoring of assigned functional area(s) including, but not limited to, PBM and Medical Drug Management (MDM) vendors, and operations compliance of formulary administration, claims processing, transition policy, Prescription Drug Event (PDEs), Explanation of Benefits (EOBs), Coverage Determinations and Exceptions, Organizational Determinations, and other Part D operational requirements.

·         Handles escalated issues and projects primarily related to assigned functional area(s) (e.g., claims, compliance concerns, and coding errors).

·         Meets regularly with PBM and Utilization Management (UM) vendors to ensure CMS and contractual compliance with all pharmacy/medical drug policies and processes.

·         Participates in internal and external audits of the Part D and Part C programs including but not limited to assigned functional area(s).

·         Provides subject matter expertise to internal staff to support Part D regulations, operational and submission requirements for the following items:

o    Coverage Gap Discount, Appeals, Grievances, Medicare Marketing        material, Quality and STARS initiatives, Medicare Application & Bid process, Employer Group Waiver Plan (EGWP) Request for Proposal (RFP) & Implementation, Benefit Testing, and Medicare Required Reporting.

·         Supports activities to foster CMS compliance awareness.

·         Performs other duties as assigned.

Medicare Pharmacy Specialist II

Supports the successful operations and compliant administration of the Medicare Pharmacy (Part D) program. Oversees Pharmacy Benefit Manager (PBM) to meet CMS compliance for all delegated activities. Acts as Subject matter expert (SME) on assigned operational aspects of Part D product and Medical Drug (Part C) program and as a liaison between internal departments and vendors.

·         Supports oversight and monitoring of assigned functional area(s) including, but not limited to, PBM and Medical Drug Management (MDM) vendors, and operations compliance of formulary administration, claims processing, transition policy, Prescription Drug Event (PDEs), Explanation of Benefits (EOBs), Coverage Determinations and Exceptions, Organizational Determinations, and other Part D operational requirements.

·         Handles escalated issues and projects primarily related to assigned functional area(s) (e.g., claims, compliance concerns, and coding errors).

·         Provides subject matter expertise to internal staff to support Part D regulations, operational and submission requirements for the following items:

o    Coverage Gap Discount, Appeals, Grievances, Medicare Marketing        material, Quality and STARS initiatives, Medicare Application & Bid process, Employer Group Waiver Plan (EGWP) Request for Proposal (RFP) & Implementation, Benefit Testing, and Medicare Required Reporting.

·         Meets regularly with PBM and Utilization Management (UM) vendors to ensure CMS and contractual compliance with all pharmacy/medical drug policies and processes.

·         Participates in internal and external audits of the Part D and Part C programs including but not limited to assigned functional area(s).

·         Supports activities to foster CMS compliance awareness.

·         Performs other duties as assigned.

Senior Medicare Pharmacy Specialist

Ensures the successful operations and compliant administration of the Medicare Pharmacy (Part D) program. Oversees Pharmacy Benefit Manager (PBM) to meet CMS compliance for all delegated activities. Acts as Subject matter expert (SME) on all operational aspects of Part D product and Medical Drug (Part C) program and as a liaison between internal departments and vendors.

·         Leads oversight and monitoring of assigned functional area(s) including, but not limited to, PBM and Medical Drug Management (MDM) vendors, and operations compliance of formulary administration, claims processing, transition policy, Prescription Drug Event (PDEs), Explanation of Benefits (EOBs), Coverage Determinations and Exceptions, Organizational Determinations, and other Part D operational requirements.

·         Leads handling escalated issues and projects primarily related to assigned functional area(s) (e.g. claims, compliance concerns, and coding errors.

·         Provides subject matter expertise to internal staff to support Part D regulations, operational and submission requirements for the following items:

o     Coverage Gap Discount, Appeals, Grievances, Medicare Marketing material, Quality and STARS initiatives, Medicare Application & Bid process, Employer Group Waiver Plan (EGWP) Request for Proposal (RFP) & Implementation, Benefit Testing, and Medicare Required Reporting.

·         Meets and leads meetings regularly with PBM and Utilization Management (UM) vendors to ensure CMS and contractual compliance with all pharmacy/medical drug policies and processes.

·         Leads internal and external audits of the Part D and Part C programs including but not limited to assigned functional area(s).

·         Initiates, facilitates, and promotes activities to foster CMS compliance awareness.

·         Performs other duties as assigned.

Qualifications

Medicare Pharmacy Specialist I

·         Bachelor's degree in business or health care administration, pharmacy, or related field.

·         In lieu of degree, may consider equivalent combination of education/training and experience.

·         2 years of experience in health plan or PBM operations, which includes Medicare Part D.

·         Medicare Part C (medical drug) experience preferred.

·         Pharmacy technician certification preferred.

·         Knowledge of Part D, managed care, and the Medicare program.

·         Knowledge of National Committee for Quality Assurance (NCQA) or general accreditation standards.

·         Knowledge of Medicare appeal and grievance processes and guidelines.

·         Intermediate Microsoft Office, database reporting and PBM systems skills.

Medicare Pharmacy Specialist II

·         Bachelor's degree in business or health care administration, pharmacy, or related field.

·         In lieu of degree, may consider equivalent combination of education/training and experience.

·         3 years progressive experience as a Medicare Pharmacy Specialist or equivalent experience in Health Plan or PBM operations, which includes Medicare Part D.

·         Medicare Part C (medical drug) experience preferred.

·         Pharmacy technician certification preferred.

·         Strong knowledge of Part D, managed care, and the Medicare program.

·         Knowledge of National Committee for Quality Assurance (NCQA) or general accreditation standards.

·         Knowledge of Medicare appeal and grievance processes and guidelines.

·         Intermediate to advanced Microsoft Office, database reporting and PBM systems skills.

Senior Medicare Pharmacy Specialist

·         Bachelor's degree in business or health care administration, pharmacy, or related field.

·         In lieu of degree, may consider equivalent combination of education/training and experience.

·         5 years progressive experience as a Medicare Pharmacy Specialist or equivalent experience in Health Plan or PBM operations, 3 years of which includes Medicare Part D.

·         Medicare Part C (medical drug) experience preferred.

·         Pharmacy technician certification preferred.

·         Comprehensive knowledge of Part D, managed care, and the Medicare program.

·         Strong knowledge of National Committee for Quality Assurance (NCQA) or general accreditation standards.

·         Strong knowledge of Medicare appeal and grievance processes and guidelines.

·         Advanced Microsoft Office, database reporting and PBM systems skills.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.