Medicare Pharmacy Specialist

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.

Job Summary:

Supports the successful operations and compliant administration of the Medicare Pharmacy (Part D) program. Oversees Pharmacy Benefit Manager (PBM) to meet CMS compliance for all delegated activities. Acts as Subject Matter Expert (SME) on assigned operational aspects of Part D product and Medical Drug (Part C) program and as a liaison between internal departments and vendors.

Responsibilities:

• Supports oversight and monitoring of assigned functional area(s) including, but not limited to, PBM and Medical Drug Management (MDM) vendors, and operations compliance of formulary administration, claims processing, transition policy, Prescription Drug Event (PDEs), Explanation of Benefits (EOBs), Coverage Determinations and Exceptions, Organizational Determinations, and other Part D operational requirements.
• Handles escalated issues and projects primarily related to assigned functional area(s) (e.g., claims, compliance concerns, and coding errors).
• Meets regularly with PBM and Utilization Management (UM) vendors to ensure CMS and contractual compliance with all pharmacy/medical drug policies and processes.
• Participates in internal and external audits of the Part D and Part C programs including but not limited to assigned functional area(s).
• Provides subject matter expertise to internal staff to support Part D regulations, operational and submission requirements for the following items:
• Coverage Gap Discount, Appeals, Grievances, Medicare Marketing material, Quality and STARS initiatives, Medicare Application & Bid process, Employer Group Waiver Plan (EGWP) Request for Proposal (RFP) & Implementation, Benefit Testing, and Medicare Required Reporting.
• Supports activities to foster CMS compliance awareness.
• Performs other duties as assigned.

Qualifications:

Education and Experience:

• Bachelor's degree in business or health care administration, pharmacy, or related field.
• In lieu of degree, may consider equivalent combination of education/training and experience.
• 2 years of experience in health plan or PBM operations, which includes Medicare Part D.
• Medicare Part C (medical drug) experience preferred.

Professional Certification(s):

• Pharmacy technician certification preferred.

Technical Skills and Knowledge:

• Knowledge of Part D, managed care, and the Medicare program.
• Knowledge of National Committee for Quality Assurance (NCQA) or general accreditation standards.
• Knowledge of Medicare appeal and grievance processes and guidelines.
• Intermediate Microsoft Office, database reporting and PBM systems skills.

Job Summary:

Supports the successful operations and compliant administration of the Medicare Pharmacy (Part D) program. Oversees Pharmacy Benefit Manager (PBM) to meet CMS compliance for all delegated activities. Acts as Subject Matter Expert (SME) on assigned operational aspects of Part D product and Medical Drug (Part C) program and as a liaison between internal departments and vendors.

Responsibilities:

• Supports oversight and monitoring of assigned functional area(s) including, but not limited to, PBM and Medical Drug Management (MDM) vendors, and operations compliance of formulary administration, claims processing, transition policy, Prescription Drug Event (PDEs), Explanation of Benefits (EOBs), Coverage Determinations and Exceptions, Organizational Determinations, and other Part D operational requirements.
• Handles escalated issues and projects primarily related to assigned functional area(s) (e.g., claims, compliance concerns, and coding errors).
• Provides subject matter expertise to internal staff to support Part D regulations, operational and submission requirements for the following…