Medicare Pharmacy Coordinator

We are seeking candidates who are currently based in Ohio for this role.

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Working under general supervision, administers typically more standardized or routine daily operations in compliance with the Medicare Part D (pharmacy) and Medicare Part C (medical drug) benefit programs. Configures, implements, maintains, and services Medicare and Individual pharmacy benefits, with a strong focus on member experience.

• Coordinates pharmacy reject review and resolution either directly or forwards/escalates to other departments or PBM. Monitors paid claims for accuracy including for transition supply oversight. Ensures timely communication to members on coverage determination and prescriptions with timeframe restrictions, assesses coverage review accuracy, and triages as needed.
• Assists in outbound calls to members, providers, and pharmacies to initiate coverage determinations/appeals, prescription refills, and switch members to lower cost therapeutic alternatives based on discussions with providers. Documents all attempts in tracking software.
• Collaborates with Clinical Intervention Pharmacists on Medicare Stars and other quality initiatives, with a strong focus on member experience. Conducts outreach to Pharmacy Benefit Manager (PBM) for refills, claim reprocessing and to members to provide status of intervention.
• Tracks and coordinates daily issue/response files with PBM for claim resolution. Outreaches to pharmacy/prescriber as needed.
• Generates reports from pharmacy system and reviews production metrics.
• Supports operational oversight overflow and any additional requests. Responds to Part D and Part B benefit questions, updates tracking documents, and ensures effectuation of claims.
• Builds and maintains knowledge of new or updated CMS regulations, Coverage Gap Discount, Coverage Determinations and Appeals, Grievances, and Medicare marketing material requirements.
• Assists in internal and external audits and projects of the Medicare Part D (pharmacy) and Part C (medical drug) programs as needed.
• Performs other duties as assigned.

• Associate Degree in Business Administration, Healthcare, or related field or equivalent combination of experience, training, and education.
• 4 - 5 years of experience in a health plan, pharmacy, or PBM operations, which includes exposure to Centers for Medicare & Medicaid Services (CMS) guidelines, preferably Part
  
  D.

• Certified Pharmacy Technician (CPhT) preferred.

• Knowledge of CMS guidelines and Medicare Part D (pharmacy).
• Knowledge of pharmacy claims processing through retail or mail pharmacy.
• Intermediate Microsoft Office skills (Excel, Word, Power Point).

Working under general supervision, administers standardized to moderately complex daily operations in compliance with the Medicare Part D (pharmacy) and Medicare Part C (medical drug) benefit programs. Configures, implements, maintains, and services Medicare and Individual pharmacy benefits, with a strong focus on member experience.

• Coordinates pharmacy reject review and resolution either directly or forwards/escalates to other departments or PBM. Monitors paid claims for accuracy including for transition supply oversight. Ensures timely communication to members on Part D coverage determination, all levels of appeal, re-openings (case re-decision) and Part C organization determination, and prescriptions with timeframe restrictions, assesses coverage review accuracy, and triages as needed.
• Coordinates remediation efforts for Hospice and End Stage Renal Disease (ESRD) processes.
• Supports Medicare Pharmacy Specialists in the…