The Pharmacy Operations Coordinator is responsible for performing oversight and monitoring of the pharmacy benefit manager (PBM), for activities related to the appropriateness of claims adjudication, and for providing support of CMS regulatory requirements, and other Plan Operations.
ESSENTIAL JOB DUTIES:
To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.
Serve as primary contact between Plan and PBM
Perform PBM oversight and monitoring
Report and escalate performance deficiencies and status to management and the compliance department
Formulary Management: Recognize formulary requirements: non-formulary, prior authorization (PA), Step Therapy (ST), Quantity Limit (QL) and review, outreach, and track rejected pharmacy claims
Responsible for ensuring regulatory requirements are met for coverage determinations/redeterminations
Lead annual readiness
Serve as a liaison with Enrollment Department to ensure appropriate member eligibility processing
Support CMS Plan reporting, audits, and monitoring activities and submissions
Assist and track in-coming calls from agents, pharmacies, nursing homes, providers/nurses, and members
Coordinate monthly website updates
Monitor and report on departmental metrics
May be assigned to work on special projects and business initiatives
Other duties as assigned
JOB REQUIREMENTS:
Maintain regular and reliable attendance
Attention to detail
Ability to work in a high demand fast pace environment
Experience in planning and implementation
Strong analytical skills
Strong leadership and collaboration skills
Extensive knowledge in Medicare compliance
Customer and quality focus
Follow-up and solve any open items in a timely manner
Adhere to all compliance requirements
Adhere to Centers of Medicare and Medicaid Services (CMS) regulations
Successful completion of required training
Handle multiple priorities effectively
Independent discretion/decision making
Make decisions under pressure
REQUIRED QUALIFICATIONS:
o High school diploma or equivalent required
o Experience in the pharmacy department of a Medicare Advantage or Part D plan is preferred
o Pharmacy technician
American Health Partners operates as a healthcare organization managing Medicare Advantage and Part D insurance plans. The company provides pharmacy benefit management (PBM) oversight and coordination, ensuring appropriate claims adjudication and regulatory compliance with CMS requirements. They manage member eligibility, formulary requirements, and coordinate between multiple stakeholders including pharmacies, providers, nursing homes, and insurance agents. The organization focuses on maintaining healthcare plan operations with emphasis on Medicare compliance and quality member services.
