Especialista De Beneficios De Farmacia

Especialista de Beneficios de Farmacia

Regular

Exempt

GENERAL DESCRIPTION:

Responsible for validating the configuration of drug benefits by medical components and pharmacy on the Pharmacy Benefit Management (PBM) platform, as well as within the internal system for both business lines. Monitors PBM activities in account management, provides customer service, modifies findings related to benefit creation, and conducts testing exercises as outlined by company contracts and in compliance with regulatory agencies.

ESSENTIAL FUNCTIONS:

•Evaluates unique policies submitted by the sales and proposals units to determine compliance and accuracy of the pharmacy benefit design administration with regulations and client requests applicable to the group quoted.

•Review Request for Proposal (RFP), plan benefit offers, and all requirements and documentation submitted by other departments related to the pharmacy benefit, which are agreed upon with customers.

•Responsible for reviewing policies and all documentation submitted by other departments related to pharmacy benefits, as approved by the Office of the Commissioner of Insurance (OCS).

•Ensure with the PBM that the benefits can be managed according to the client's request, before and during the negotiations.

•Ensure timely deliveries, maintain high quality standards, and utilize resources efficiently to achieve accuracy in claims adjudication, and address situations arising from benefit designs and researching basic claims adjudication issues or inquiries.

•Provides input to management and other departments on matters related to payment rule adjudications, the method of setup and monitoring of claims and pending cases needing intervention from other departments. Analyzes changes in federal or local regulations that impact existing products and identifies the critical areas impacted for work plan development.

•Support, create, and maintain documentation for customer plan designs, detailing custom maintenance processes and configuration best practices. This includes documenting allocation hierarchies, editions, constraints, tables, carriers, and other configuration components.

•Ensures ongoing customer satisfaction through consultation and collaboration with internal business partners to ensure business requirements for submitted change requests are seamlessly understood, documented, developed, communicated, tested, and delivered.

•Reviews the test results in the unit to validate the new configurations of the pharmacy benefit design.

•Responsible for managing tasks associated with the recovery of pharmacy services for different lines of business as requested by other entities, and for ensuring proper payment by the company.

•Provides reports of operational metrics and findings trends to the management.

•Provides support in audits and pharmacy benefit design monitoring for the various lines of business.

• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.

• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelor's Degree in Healthcare Administration, Pharmacy, Business Administration, or related fields. At least three (3) years of experience working in a health plan or in a PBM (Pharmacy Benefit Management) managing pharmacy benefits.

OR

Education and Experience: Associate Degree in Pharmacy Technician. At least four (4) years of experience working in a health plan or in a PBM (Pharmacy Benefit Management) managing pharmacy benefits.

"Proven experience may be replaced by previously established requirements."

Certifications / Licenses: For an Associate's Degree, a valid Pharmacy Technician license and registration is required. Other: Knowledge of benefits rules as defined in the Medicare Manuals. Knowledge and interpretation of the standard rating systems (CPT, ICD-10, HCPCS) is preferred.

Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)

"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento"