Pharmacy Benefits Consultant

2 weeks ago

Springfield, United States PacificSource Health Plans Full time

***Candidates must be located in the general Springfield/Eugene area***

Assist in all facets of the pharmacy benefit and reporting while collaborating with Pharmacy leadership to design, implement, and coordinate pharmacy program initiatives. Engage with the pharmacy benefit and work alongside the Pharmacy team to execute and manage pharmacy initiatives, including compliance and quality performance metrics. Key focus areas encompass Pharmacy Benefit Management (PBM) operations, utilization management platform operations, pharmacy/data analytics, and business analysis and process enhancement.

Key Responsibilities:

  • Oversee and ensure quality assurance for the accurate establishment of pharmacy benefit designs, formulary coding, network coding reporting, and drug pricing through PBM configuration testing and claims analysis.
  • Collaborate with Sales, Product Development, and Pharmacy teams to guarantee precise and optimal pharmacy benefit designs and initiatives.
  • Support the Sales team by generating and analyzing claims data, formulary comparisons, and projections for both new and existing groups.
  • Manage the 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.
  • Assist formulary administrators and leadership on initiatives, tasks, and projects related to all aspects of the plans' pharmacy benefit across all lines of business (Medicare, Medicaid, Commercial).
  • Conduct ongoing drug and claim configuration setup and testing to ensure the accuracy of point-of-service adjudication.
  • Provide claims research, analysis, and support during internal and external audits.
  • Investigate, troubleshoot, and resolve claims issues, along with reviewing and documenting service warranties.
  • Generate and analyze reports for new and transitioning groups.
  • Develop and maintain Pharmacy department policies and procedures to reflect new best practices and guidance.
  • Organize, document, and support departmental performance dashboards.
  • Track and record drugs at launch for clinicians to facilitate potential coverage and formulary decisions.
  • Support ongoing communication efforts, including notifications to members, pharmacies, and providers.
  • Create reports in internal reporting software and perform accurate and complete data extraction from our data warehouse to meet the demands of pharmacy reporting, analysis, and projections.
  • Analyze medical and pharmacy claims to identify cost-saving opportunities and process improvements, facilitating cross-departmental prioritization of pharmacy initiatives.
  • Present complex data, analysis, and findings to internal and external teams in a clear and understandable manner.
  • Participate in special projects and committees.

Supporting Responsibilities:

  • Meet department and company performance and attendance expectations.
  • Adhere to privacy policies and regulations concerning confidentiality and security of protected health information.
  • Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: A minimum of five years of experience in a healthcare-related field is required. Preference for experience within managed care or pharmacy settings. Experience with quality performance metrics and standards is preferred.

Education, Certificates, Licenses: A Bachelor's degree is required, preferably in public health, healthcare-related fields, mathematics, statistics, data science, or similar research-related disciplines, or equivalent years of relevant experience in lieu of a degree. Strong preference for certification in data software such as RxClaim, SQL, SAS, Excel, or Tableau.

Knowledge: Proficient computer skills are essential. Strong capabilities in Microsoft applications, including Word and Excel, are required. Excellent verbal and written communication skills are necessary. A solid understanding of Medical Terminology is required. The ability to define and prioritize problems and manage workload independently is crucial. Must be able to work within tight timeframes and meet strict deadlines. In-depth knowledge of the RxClaim PBM software is necessary. Skills in claims analysis to identify complex problems and propose solutions are required. Coding and analytics knowledge is essential, with SQL experience preferred.

Competencies

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment: Work is conducted in a general office setting with ergonomically configured equipment. Travel may be required approximately 10% of the time.

Skills:

Accountability, Communication, Flexibility, Active Listening, Organizational Skills, Problem Solving, Teamwork

Our Values

We are committed to our core values that guide our business practices:

  • We are dedicated to doing the right thing.
  • We function as one team working towards a common goal.
  • We each take responsibility for customer service.
  • We promote open communication at all levels to foster growth.
  • We actively engage in efforts to improve our communities.
  • We strive to advance social justice, equity, diversity, and inclusion.
  • We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Ability to stoop and bend. Must be able to sit and/or stand for extended periods while performing core job functions. Repetitive motions, including typing, sorting, and filing, are required. Light lifting and carrying of files and business materials may be necessary. Ability to read and comprehend both written and spoken English is essential. Clear and effective communication is required.

Disclaimer: This job description outlines the general nature and level of work performed by employees in this position and is subject to change. It is not intended to be a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains at-will at all times.

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace where individual differences are appreciated and respected.

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