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Pharmacy Network Management Specialist

4 months ago

Philadelphia, United States Infojini Full time
• Under the general observation of the Supervisor Pharmacy Network Management, assists the Supervisor in the evaluation, reporting and monitoring of all aspects pertaining to Pharmacy Network services

• Ensure pharmacies and staff meets federal and state guidelines.

• Tracking and monitoring pharmacy contracts/credentials to ensure compliance with plan standards, accreditation agencies and state and federal regulatory guidelines.

• Maintaining up to date contract, addendums, and notices on Pharmacies to ensure contract compliance.

• Coordinates and evaluates the pharmacy network maintenance.

• Analyzes and participates in the contracting of new and existing pharmacies within the PerformRx Pharmacy Network.

• Maintaining up to date credentialing on pharmacies to ensure contract compliance.

• Issuing notification to pharmacies when there are lapses in compliance information.

• Executing updated Pharmacy contract drug rate information.

• Ensuring contracted rates are properly recorded and communicated within the PerformRx claims processing system as well as the PerformRx data bases.

• Ensuring integrity is maintained within various data, i.e. Argus SNA and the PerformRx Access database.

• Reviewing, mailing and communicating with Pharmacy staff on new contracts and other issues as they arise.

• Validating claims processing SNA system to ensure contracted rates are reelected within the claims processing system.

• Updating information against the NCPDP file for address, new and closed pharmacies, and other key metric information as needed.

• Prepare various pharmacy network reports compiling metrics regarding contracts and credentials.

• Suspend/ remove pharmacies from the network not meeting contracted and credentialing requirements.

• Manage and monitor each client network structure with the Pharmacy Network database, SNA and claims processing system.

• Responding to Pharmacy complaints by researching and communicating issues to internal groups or escalating according to department and company policy. Providing explanations on claim status, policy changes and payment decisions. Coordinating activities impacting inter/intra departments to ensure smooth coordination of members related inquiries.

• Maintains proactive and effective communication with all members of the departmental team and communicates any concerns appropriate staff immediately. Continuously evaluates administrative operational procedures and recommends changes as appropriate

• Performs other related duties and projects as assigned. Including communications to Pharmacies and other related entities as needed. Participating in executed contract activities as needed. Attends required training as necessary.

• Adheres to PerformRx/ACFC policies and procedures. Maintains a current knowledge base of program services, policy and procedures. Regularly reviews and reacts to policy updates and departmental procedures.

• Creates and supports an environment which fosters teamwork, cooperation, respect and diversity. Establishes and maintains positive communication and professional demeanor with PerformRx employees and clients at all times. Demonstrates and supports commitment to corporate goals and mission.

Skills: • REQUIRED 3-5 years pharmacy network experience.

• Understanding of URAC and CMS network requirements.

• Understanding of state level network requirements.

• Excellent written and verbal communication skills.

• Healthcare knowledge preferred.

• Previous customer service experience in a managed care environment.

Education:

• Bachelor's Degree REQUIRED

• Current Pharmacy Technician (PTCB) Certification REQUIRED