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This position performs routine and complex quality audits of Pharmacy processes (coverage and member reimbursement determinations, redeterminations, Medication Therapy Management [MTM]). This role verifies the completeness and accuracy of technician's casework, as well as adherence to federal and state regulations, accreditation standards, contractual requirements, and departmental policies, procedures and guidelines. Responsible for conducting scoring of casework, providing individualized feedback of audit results, and the identification of trending issues. Recommends improvements to departmental policies, procedures, guidelines and/or training practices as appropriate.
Conducts quality reviews of pharmacy coverage determination, member reimbursement determination, and redetermination processes.
Conducts quality reviews of authorizations originating from PBM systems associated with coverage determinations/redeterminations.
Conducts quality reviews of MTM technician and pharmacist processes (i.e. call handling, data entry, etc).
Reviews casework (all areas of Pharmacy) for thoroughness, accuracy, and compliance requirements in accordance with WellCare and any government (Federal or State) processes.
In conjunction with supervisor, coaches and provides written feedback to individuals and management based on error findings.
Tracks and maintains quality results for appropriate distribution.
Communicates audit results in a structured report format.
Demonstrates and applies subject matter expertise related to Pharmacy Operations processes for all WellCare lines of business (e.g. Medicare, PDP, Medicaid).
Assists with identification and communication of process improvement opportunities across pharmacy department.
Follows all state and federal regulations and contractual requirements, including record retention requirements.
Conducts ad-hoc projects as needed.
Performs other duties as assigned.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Preferred A Bachelor's Degree in a related field
Required 3 years of experience in Pharmacy, Claims, Quality, or Customer Service related work
Preferred 2 years of experience in Pharmacy technician experience in a managed care, retail or hospital setting
Preferred 1 year of experience in Managed care pharmacy and/or appeals/grievances
Preferred 1 year of experience in Demonstrated experience supporting multiple pharmacy specialties (i.e. coverage determinations and/or redeterminations, MTM)
Preferred Other Familiarity with the pharmacy software utilized by WellCare and the PBM is a plus.
Preferred Other Previous experience with government programs such as Medicare and Medicaid
Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Skills in workflow, reporting systems and databases
Intermediate Ability to work as part of a team Drug knowledge and/or knowledge of all workflow systems
Intermediate Ability to work independently
Intermediate Demonstrated written communication skills
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated time management and priority setting skills
Intermediate Demonstrated problem solving skills
Intermediate Other Ability to use pharmaceutical references
Intermediate Other Working knowledge of prescription medications and pharmacotherapy
Intermediate Other Ability to perform detailed review, research and analysis to ensure Operational accuracy across multitude of systems
Intermediate Other Demonstrated technical expertise in performing quality reviews along with analysis of results
Licenses and Certifications: A license in one of the following is required: