Pharmacy Benefits Specialist
2 weeks ago
Position Summary:
The Pharmacy Benefits Specialist plays a crucial role in facilitating clinical outreach services to our members, their pharmacies, and healthcare providers. This position is dedicated to ensuring member safety, addressing care gaps, identifying cost-effective medication solutions, and coordinating care to enhance healthcare outcomes for our members. The role also supports HEDIS adherence initiatives and contributes to longitudinal improvement objectives.
Key Responsibilities:
- Collaborate with quality management teams to assist in HEDIS adherence projects.
- Ensure accurate implementation and coding of pharmacy benefits, formulary, and program modifications, including the review of PBM testing scenarios.
- Evaluate pharmacy service denial recommendations, investigating and reviewing relevant data from plan providers.
- Assist in member management by gathering essential information from plan providers and pharmacy data systems.
- Support various pharmacy, utilization review/management, quality improvement, provider relations, and population health initiatives.
- Act as a pharmacy liaison and resource for plan pharmacies and members.
- Assist the Pharmacist in monitoring and evaluating pharmacy utilization.
Required Knowledge and Skills:
- Comprehensive understanding of prescription benefit management (PBM) programs and practices.
- Ability to identify, articulate findings, and resolve issues related to members, providers, processes, and systems, with effective verbal and written communication.
- Proficient business writing and presentation skills, including report writing.
- Exceptional attention to detail, particularly in interpreting and understanding benefits and codes.
- Familiarity with government relations and the ability to operationalize and comprehend the interdependencies of various regulatory aspects.
Education and Experience Requirements:
- High School diploma or GED, or equivalent.
- Current Maryland State Pharmacy Technician licensure, with certification from a nationally recognized Pharmacy Technician Certification Board.
- A minimum of two (2) years of experience as a pharmacy technician.
- Experience in a managed care, insurance, PBM, or similar environment is strongly preferred.
- Experience in supporting utilization management or prior authorization processes.
Commitment to Diversity:
Maryland Care Management, Inc. is dedicated to fostering an inclusive workplace that values diversity and promotes equal opportunity. We believe that a diverse workforce enhances our ability to serve our members effectively. We encourage individuals from all backgrounds to consider a career with us, as we strive to provide compassionate and culturally competent healthcare services.
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