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WellCare - Pharmacy Leadership Careers

Pharmacy Benefit Relations - Director Job

Full Job Title: Director, Pharmacy Benefit Relations

Job Number: 1705064

Location: Tampa, FL

Date Posted: 12-13-2017

Department: Pharmacy State and Benefits
Reports to: Sr. Director Pharmacy Benefits Relations
Location: 4110 George Road, Tampa FL 33634

Works in conjunction with the Sr. Director to act as a liaison between WellCare and the Pharmacy Benefits Manager (PBM), CatalystRx, in regards to all aspects of pharmacy claims processing. Works daily with CatalystRx and oversees all initiatives that require CatalystRx engagement in pharmacy processing, formulary setup, prescription editing, network audit, data files and benefit structure. Ensures the implementation of initiatives is achieved without setbacks through proper quality assessment measures and planning. Oversees the project management of all CatalystRx initiatives. Coordinates ancillary services provided by the PBM, regulatory reporting and oversight of the PDE process. The position is also responsible for providing operational oversight of pharmacy investigative team efforts relating Pharmacy Fraud, Waste & Abuse (FWA). Provides leadership to the Pharmacy FWA team and provides guidance relating to daily investigative efforts, work flows, coordination with WellCare's SIU. The position has oversight authority over the Pharmacy Quality Assurance program for coverage determinations and redeterminations, which includes Intake, DER, Appeals and DMRs quality. The incumbent is responsible for monitoring productivity and the quality of the QA's being completed by the pharmacy Quality Auditors. The individual will also have ancillary pharmacy responsibilities including working with the Sr. Director to oversee the project management aspect of the Pharmacy department. The position provides guidance to the Project Manager and cross-functional support when coordination and escalation are necessary. The individual will also oversee the relationships with State Pharmacy Assistance Programs (SPAPs) that partner with WellCare to provider supplemental benefits to beneficiaries. The individual is responsible for creating and maintaining positive relationships with the state entities.

Essential Functions:

  • Oversees all regulatory reporting requirements that are provided by CatalystRx
  • Ensures appropriate setup of defined new plans and changes in benefit and copay structure.
  • Ensures proper loading of membership for prescription benefits from Wellcare enrollment to CatalystRx.
  • Ensures that processes subject to regulatory requirements are being met. Examples of processes are EOB, transition letters, and price file downloads.
  • Liaises with Sr Director to oversee and selects the additions and maintenance of the pharmacy network.
  • Oversees data files that are exchanged through CatalystRx and WellCare.
  • Responsible for monitoring QA productivity and quality.
  • Builds & maintains relationships with State Pharmacy Assistance Programs (SPAPs).
  • Oversees the Pharmacy FWA team and escalations to SIU pertaining to incidents of suspected healthcare fraud and abuse.
  • Supports pharmacy FWA analysis, including the review, summarization and dissemination of key regulatory updates and changes.
  • Performs other duties as assigned.
Candidate Education:
  • Required A Bachelor's Degree in Business or related field
  • Preferred A Master's Degree in Business or related field
Candidate Experience:
  • Required 10 years of experience in pharmacy benefits with Medicare Part D knowledge
  • Required Other Understanding of pharmacy claims processing, pharmacy FWA, network audits, pharmacy benefits structure, formularies, and Medicare and Medicaid prescription plans and requirement
Candidate Skills:
  • Advanced Ability to analyze information and covert related activities into a comprehensive work plan
  • Advanced Ability to communicate and make recommendations to upper management
  • Advanced Ability to effectively present information and respond to questions from peers and management
  • Advanced Ability to influence internal and external constituents
  • Advanced Ability to influence internal and external constituents
  • Advanced Ability to represent the company with external constituents
  • Advanced Demonstrated customer service skills
  • Advanced Demonstrated interpersonal/verbal communication skills
  • Advanced Demonstrated problem solving skills
  • Advanced Demonstrated written communication skills
  • Advanced Demonstrated negotiation skills
Licenses and Certifications:Technical Skills:
  • Required Intermediate Microsoft Excel
  • Required Intermediate Microsoft Word
  • Required Intermediate Microsoft PowerPoint
  • Required Intermediate Microsoft Project
  • Required Intermediate Healthcare Management Systems (Generic)

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Last Updated On: 12/9/2015