Department: Pharmacy - Benefit Relations
Reports to: Sr. Director Pharmacy Benefits Relations
Location: 4110 George Road, Tampa FL 33634
This position may support either the pharmacy benefit (PBM) or formulary areas of Pharmacy. Will oversee pharmacy benefit systems and ensure data is set up accurately by the PBM and thus serves as additional layer of quality assurance and testing for delegated functions relating to claim adjudication. Analyzes benefit requests and researches all necessary data points to ensure PBM coding is generating outputs. Responsible for validating outcomes of the research completed. Supports the short and long term success of the department through the QA oversight of all PBM data interfaces to ensure control points are in place to confirm delivery & receipt of files, claim file accuracy and completion, and validates correct data field mapping.
Additional Responsibilities:Candidate Education:
- Applies an in-depth knowledge of the RxCLAIM PBM software to conduct and manage outcomes of PBM or formulary benefit programming coding.
- Applies knowledge of pharmacy policy to ensure claims have processed appropriately based on benefit design and/or preferred drug list.
- Reviews and validates system generated outputs through analyzing pharmacy benefit claim adjudication and claim file set-up.
- Evaluates all PBM coding including pharmacy benefit relations, formulary, PDL set-up, and network coding. Scope of research includes not only validation of all programming requests sent to the PBM but also continuous coding updates performed by the PBM relating to the plan and Medispan updates.
- Runs queries out of the RxCLAIM adjudication system to secure all necessary information to implement plan requests.
- Creates and analyzes pharmacy reports and data files in support of the team.
- Presents the results of research and analysis to key pharmacy stakeholders to ensure business objective are met.
- Serves as the point of contact for all pharmacy benefit or formulary coding issues identified so that pre-validation can be performed. Provides explanations and interpretations within area of expertise.
- Monitors PBM coding for compliance and regulatory requirements and participates in audit related activities to include but not limited to coding research, running program queries and meeting with internal and external partners.
- Serves as primary point of contact for PBM new business implementation.
- Additional projects as assigned.
- Required A High School or GED
- Preferred A Bachelor's Degree in Business, Computer Science or related field
- Required 2 years of experience in 2-3 years Pharmacy, PBM, Health Plan, or Information Systems experience
Licenses and Certifications:
- Intermediate Other Strong oral and written communication skills to effectively communicate clearly with people both within and outside the organization.
- Intermediate Other Ability to read, analyze, and interpret general business documents, policies and procedures or technical procedures.
- Intermediate Other Ability to write reports, business correspondence and training documents.
- Intermediate Other Ability to effectively present information and respond to questions from Pharmacy Management and Pharmacy Technicians.
- Intermediate Other Ability to interpret a complex variety of technical instructions, and deal with several abstract and concrete variables.
- Intermediate Other Experience with RxCLAIM, PBM Systems or Pharmacy Systems Preferred
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Demonstrated analytical skills
A license in one of the following is required:
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Access
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Visio
- Required Intermediate Microsoft Word
- Preferred Intermediate Visual Basics
- Preferred Intermediate Other SQL Server System – i.e.: PL SQL, TOAD, MYSQL
- Preferred Intermediate Oracle Database Management System (DBMS)