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Medication Management Specialist

2 months ago

Doral, Florida, United States Leon Medical Centers Full time

SUMMARY

The Medication Management Specialist plays a crucial role in ensuring that Leon Medical Centers' members receive all necessary prescription medications in a safe and cost-effective manner, while adhering to all applicable federal and state regulations.

Key responsibilities encompass formulary oversight (including the assessment of prior authorization requirements, analysis of drug utilization patterns, and management of pharmacy expenses), clinical pharmacy services (such as therapeutic drug monitoring, medication regimen evaluation, patient education, and collaboration with medical staff), and quality assurance (developing and evaluating performance metrics related to patient outcomes, medication safety, and medication use policies).


ESSENTIAL DUTIES AND RESPONSIBILITIES
Communicates pharmacy decisions in accordance with clinical guidelines and organizational policies.
Assesses pharmacy requests received through various channels, applying clinical criteria to determine medication appropriateness.
Conveys decisions to healthcare providers, medical management personnel, members, and pharmacists.
Conducts clinical research to support requests and identifies additional information needed to complete patient records.

Engages in electronic or verbal outreach (e.g., email, fax) to pharmacies and healthcare providers to gather all necessary information related to requests, including member assistance when required.

Handles non-medical inquiries such as eligibility verification, coordination of benefits, and Part D benefit confirmation.
Maintains precise and comprehensive documentation in compliance with regulatory standards and company policies.
Ensures that medication requests adhere to all federal and state regulations.
Facilitates effective communication with Case Managers, other health plan personnel, and healthcare providers.
Encourages open communication, both internally and externally, to improve the efficiency of pharmacy services.
Escalates complex requests to Pharmacists when extensive clinical review or denial is necessary.
Assists members with inquiries regarding the formulary process.
Exhibits professionalism and courtesy towards patients, visitors, callers, and colleagues.

Maintains open lines of communication with administrative staff and other departments; responds to all inquiries in a professional and courteous manner.

Participates in training and educational sessions as required.
Engages in departmental, clinic, and other meetings as requested.
Adheres to organizational policies and procedures while maintaining confidentiality in accordance with state and federal laws.
Contributes to special projects and performs additional duties as assigned.

QUALIFICATIONS
A minimum of three (3) years of experience as a Pharmacy Technician, with a focus on reviewing, designing, and configuring pharmacy claims processing and/or formulary maintenance systems, as well as supporting comprehensive coordination of Medicare Part D pharmacy services, including the intake and processing of pharmacy authorization requests.
Current or recent experience in a Pharmacy Benefit Manager (PBM) or managed care pharmacy setting is preferred.
Proficiency in computerized pharmacy systems and software applications.
Extensive experience with Medicare Part D claims.
Demonstrated proficiency in the English language, with effective verbal and written communication skills.
Knowledge of pharmacy practices and procedures, with the ability to interpret pharmaceutical information.
Familiarity with drug dosage forms, strengths, and generic and trade name equivalents.
Understanding of federal and state laws/regulations governing pharmacy services.
Ability to manage multiple tasks and prioritize effectively.
Flexibility to adapt to changing business and departmental needs.
Strong communication skills (listening, verbal, and written).
Proficient in Microsoft Word, Excel, and Outlook.
Excellent organizational skills and attention to detail.
Experience in a members and providers call center is preferred.
Intermediate proficiency in MS Excel (including formula writing, filtering, and managing large data sets).

EDUCATION
High School Diploma

LANGUAGE SKILLS
Bilingual fluency in English and Spanish.
CERTIFICATES, LICENSES, REGISTRATIONS
A valid Florida Pharmacy Technician License
National Certification (CPHT)
PHYSICAL DEMANDS/WORK ENVIRONMENT
Work hours may vary based on organizational needs. All full-time employees are expected to complete forty (40) hours per week as scheduled, including weekends and holidays. The position may require extended hours when necessary.

The physical demands and work environment characteristics described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This role requires various physical activities, including climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing, and visual acuity.

The work is performed indoors.

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