Full Job Title: Pharmacy Formulary Coordinator, Sr.
Job Number: 1704653
Location: Tampa, FL
Date Posted: 10-31-2017
Coordinates and controls the workflow occurring in and out of the department. Tracks and reviews the development and maintenance of the Medicare formularies, Medicaid Preferred Drug Lists (PDL's) and all coding changes sent to the Pharmacy Benefit Manager (PBM) by line of business. Partners closely and coordinates with other pharmacy and functional departments on a frequent basis to ensure synergies and cross-departmental effectiveness.
Key Duties and Responsibilities
• Reviews and tracks all aspects of pharmacy claims processing and formulary management for completeness and coding accuracy. (i.e. Medispan information and changes sent to PBM for coding)
• Develops and maintains Medicare Formularies and Medicaid Preferred Drug Lists, PDLs.
• Audits the formularies and PDL's to ensure the terms of agreement have been loaded accurately.
• Serves as the department's audit lead for claims research, analytics, and support (i.e. Acumen, TMPA, CMS program audit, rebate audits).
• Works with channel and digital communications for all Medicare comprehensive formularies and Notice of Change website postings to maintain CMS compliance.
• Under the direction of a pharmacist, handles formulary medical / drug related questions from the WellCare call center and ensures formulary and preferred drug list changes have been communicated to internal partners.
• Supports Formulary leadership on initiatives, tasks and projects related to all aspects of the plans' pharmacy benefit for all lines of business (e.g. Medicare, PDP, Medicaid).
• Researches and resolves routine provider operational issues with internal and external partners.
• Troubleshoots claims issues with internal and external partners.
• Oversees the weekly and monthly receipt of Third Party Vendor files.
• Completes ongoing test claims and claim review for PBM oversight and logic analysis.
• Pulls daily reports from the log review for tracking and trending, and alerts the vendor account manager to ongoing issues.
•Serves as SME for pharmacy PDL and formulary related issues.
• Facilitates in-service education sessions for technicians on formulary changes and preferred drug lists and for coordinators on PBM coding updates.
• Supports manager with onboarding and training of new coordinators.
• Maintains tools Step Actions and Job Aids.
• Maintains PBM activity and error logs to measure accuracy of Medicare and Medicaid coding.
• Performs special projects as assigned or directed.