Pharmacy Benefits Consultant

1 week ago

South Bend, Indiana, United States PacificSource Full time
Are you passionate about improving healthcare access and quality?

At PacificSource, we are dedicated to ensuring our members receive affordable and high-quality care.

Equal Opportunity Employer: PacificSource is committed to diversity and inclusion. We welcome applicants from all backgrounds and experiences, ensuring a fair hiring process without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age, or disability status.

Role Overview: As a Pharmacy Benefits Consultant, you will play a crucial role in supporting all facets of pharmacy benefits and reporting. Collaborate with Pharmacy leadership to design, implement, and coordinate pharmacy program initiatives. Your focus will include Pharmacy Benefit Management (PBM) operations, utilization management, data analytics, and business process enhancement.

Key Responsibilities:
  • Oversee and ensure quality assurance for the accurate setup of pharmacy benefit designs, formulary coding, network coding reporting, and drug pricing through rigorous PBM configuration testing and claims analysis.
  • Work collaboratively with Sales, Product Development, and Pharmacy teams to optimize pharmacy benefit designs and initiatives.
  • Assist the Sales team by generating and analyzing claims data, formulary comparisons, and projections for both new and existing groups.
  • Manage the interface between vendors, consultants, and clients to ensure efficient coordination and implementation of coding, including oversight of all PBM operations and data interfaces.
  • Support formulary administrators and leadership on initiatives related to the pharmacy benefit across all lines of business, including Medicare, Medicaid, and Commercial.
  • Conduct ongoing drug and claim configuration setup and testing to ensure accuracy in point-of-service adjudication.
  • Provide claims research, analysis, and support during both internal and external audits.
  • Investigate, troubleshoot, and resolve claims issues while documenting service warranties.
  • Generate and analyze reports for new and transitioning groups.
  • Develop and maintain Pharmacy department policies and procedures to reflect best practices and guidance.
  • Organize and support departmental performance dashboards.
  • Track and document drug launches to assist clinicians in making coverage and formulary decisions.
  • Facilitate ongoing communication efforts, including notifications to members, pharmacies, and providers.
  • Create reports using internal reporting software and accurately extract data from our data warehouse to meet pharmacy reporting and analysis needs.
  • Analyze medical and pharmacy claims to identify cost-saving opportunities and process improvements, prioritizing pharmacy initiatives across departments.
  • Present complex data and findings to internal and external teams in a clear and comprehensible manner.
  • Participate in special projects and committees as needed.
Supporting Responsibilities:
  • Meet departmental and company performance and attendance expectations.
  • Adhere to PacificSource privacy policies and HIPAA regulations regarding the confidentiality and security of protected health information.
  • Perform additional duties as assigned.
Success Profile:

Work Experience: A minimum of five years in a healthcare-related field is required, with a preference for experience in managed care or pharmacy. Familiarity with Medicare Star ratings, Medicaid quality initiatives, and NCQA standards is preferred.

Education, Certificates, Licenses: A Bachelor's degree is required, preferably in public health, healthcare, mathematics, statistics, data science, or a related field. Relevant experience may be considered in lieu of a degree. Certification in data software such as RxClaim, SQL, SAS, Excel, or Tableau is highly preferred.

Knowledge and Skills: Strong computer skills, particularly in Microsoft applications like Word and Excel. Excellent verbal and written communication skills are essential, along with a solid understanding of medical terminology. The ability to prioritize problems and manage workload independently is crucial, as is the capacity to work under tight deadlines. Familiarity with RxClaim PBM software and claims analysis is required, 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
Work Environment: This position is based in a general office setting with ergonomically configured equipment. Travel may be required approximately 10% of the time.

Physical Requirements: The role requires the ability to stoop, bend, sit, and/or stand for extended periods while performing core job functions. Repetitive motions such as typing, sorting, and filing are necessary, along with light lifting and carrying of files and materials. Proficiency in reading and comprehending written and spoken English is essential, as is the ability to communicate clearly and effectively.

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 for this role.

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