Pharmacy Operations Specialist

6 days ago

South Bend, Indiana, United States PacificSource Full time
About the Role

PacificSource is seeking a highly skilled Pharmacy Benefits Strategist to join our team. As a key member of our pharmacy operations team, you will play a critical role in designing, implementing, and coordinating pharmacy program initiatives.

Key Responsibilities
  • Pharmacy Benefit Design and Management: Provide oversight and quality assurance to ensure accurate setup of pharmacy benefit designs, formulary coding, network coding reporting, drug pricing, through PBM configuration testing and claims analysis.
  • Collaboration and Communication: Collaborate with Sales, Product Development, and Pharmacy teams to ensure accurate and optimal pharmacy benefit designs and initiatives.
  • Claims Analysis and Reporting: Support Sales team by generating and analyzing claims data, formulary comparisons, and projections for new and existing groups.
  • Vendor and Consultant Management: Manage interface between vendor/consultant/client to ensure efficient coordination and implementation of coding, including appropriate oversight and monitoring of all PBM operations, data interfaces, and external communications.
  • Formulary Administration: Support formulary administrators and leadership on initiatives, tasks, and projects related to all aspects of the plans' pharmacy benefit for all lines of business (Medicare, Medicaid, Commercial).
  • Claims Research and Resolution: Perform ongoing drug and claim configuration setup and testing to ensure accuracy of point of service adjudication. Provide claims research, analysis, and support during internal and external audits.
  • Reporting and Analytics: Generate and analyze reports for new and transitioning groups. Develop Pharmacy department policies and procedures as applicable and regular maintenance to reflect new best practices and guidance.
  • Communication and Collaboration: Organize, document, and support departmental performance dashboards. Track and record drugs at launch for clinicians to make potential coverage and formulary decisions. Support ongoing communication efforts including member, pharmacy, and provider notifications.
  • Business Analysis and Process Improvement: Analyze medical and pharmacy claims to identify cost savings opportunities and process improvements and facilitate cross-departmental prioritization of pharmacy initiatives.
  • Presentations and Reporting: Present complex data, analysis, and findings to internal and external teams in a way that is clear and understandable.
Requirements
  • Work Experience: Minimum of five years of experience within a healthcare field. Preference for experience within managed care or pharmacy. Preference for experience with Medicare Star ratings, Medicaid quality initiatives, and NCQA standards. Preference for experience with Pharmacy benefit managers and project management.
  • Education and Certifications: Bachelor's degree required, with preference on degree in public health, healthcare-related, mathematics, statistics, data science, or similar research-related field, or equivalent years of relevant experience in lieu of degree. Strong preference for certification in data software such as RxClaim, SQL, SAS, Excel, Tableau.
  • Skills and Competencies: Strong computer skills. Strong skills within Microsoft application software including Word and Excel. Excellent verbal and business writing skills. Excellent public relations skills. Good understanding of Medical Terminology required. Requires ability to define and prioritize problems and manage workload without direct supervision. Ability to work within tight timeframes and meet strict deadlines. Ability to gain in-depth knowledge of the RxClaim PBM software. Ability to perform claims analysis to find complex problems and identify solutions. Coding and analytics knowledge required. SQL experience preferred.
About PacificSource

PacificSource is an equal opportunity employer. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected, and responded to in ways that fully develop and utilize each person's talents and strengths. We value the diversity of the people we hire and serve.

Our Values
  • We are committed to doing the right thing.
  • We are one team working toward a common goal.
  • We are each responsible for customer service.
  • We practice open communication at all levels of the company to foster individual, team, and company growth.
  • We actively participate in efforts to improve our many communities-internally and externally.
  • We actively work to advance social justice, equity, diversity, and inclusion in our workplace, the healthcare system, and community.
  • We encourage creativity, innovation, and the pursuit of excellence.

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