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Medicare Pharmacy Benefit Coordinator

3 months ago

Honolulu, United States HMSA Full time
  1. Support the pharmacy strategy from a Medicare benefit design and delivery perspective.
    • Maintain a deep understanding of Medicare benefits.
    • Work with internal HMSA staff to drive benefit design and delivery that will foster ideal member care.
      • Analyze business needs and data, develop feasible solutions, implement changes, and evaluate effectiveness of changes.
    • Work with external stakeholders such as the Pharmacy Benefit Manager (PBM) to operationalize benefits.
      • Collaborate with the PBM to provide the best benefit product/service.
      • Perform oversight of the PBM and other entities as applicable to ensure the benefit is provided as intended.
      • Implement, test, and evaluate changes made within the PBM
  2. Lead and support project management and communications.
    • Manage projects that coordinate and implement clinical initiatives and/or pharmacy benefit operations and improvements.
      • Conduct research, evaluation of measures and value assessments of initiatives and/or programs.
      • Assess compliance with Federal and State regulations, internal policies, procedures, and workflows.
      • Streamline workflows.
      • Review and edit requirements, specifications, business processes and recommendations related to proposed solutions.
      • Coordinate and facilitate planning, tracking, and installation of business requirements and deliverables.
    • Perform outreach as necessary to support pharmacy and quality strategies.
    • Provide quality, objective, and professional analyses of business needs and PBM capabilities/limitations.
    • Develop communications as appropriate to facilitate ideal utilization of pharmacy benefits.
    • Develop policy and procedures, work instructions, training materials, and employee training.
  3. Manage incoming Pharmacy Management inquiries with a superior level of customer service.
    • Coordinate problem solving associated with inquiries and follow through to resolution.
    • Identify root causes of individual and/or trending encounters and carry out process improvement initiatives.
    • Triage inquiries, if necessary, to ensure servicing needs are properly identified and addressed.
  4. Lead Medicare Point-of-Sale Operational Tasks.
    • Reconcile all benefit and coding related documents to ensure accuracy and timely updates as necessary
    • Define acceptance testing criteria and ensure that the criteria are met before system changes are implemented
    • Maintain PBM system functionality to ensure operational efficienc
    • Monitor and evaluate accuracy of pharmacy drug benefit through testing review and validations; report monitoring and/or live claim review.
    • Ensure HMSA meets performance standards stated by government regulations, employer groups, Blue Cross Blue Shield Association, internal policies, procedures, workflows and business requirements.
  5. Manage special projects as assigned.
  6. Performs all other miscellaneous responsibilities and duties as assigned or directed.