Especialista De Estrellas En Farmacia

Especialista de Estrellas en Farmacia




GENERAL DESCRIPTION:

Responsible for the setting, implementation, and monitoring of initiatives to enhance efficiency and improvement of quality measures for Medicare contracts. Ensure that the unit operates at an optimal and efficient level and identifies and implements process improvements or new initiatives that positively impact the quality measures for the unit. Generate reports and maintain records of initiatives and special assignments that contribute to achieving quality measure goals. Monitors the turnaround time (TaT) and trends for referrals to the pharmacy department from the Customer Relationship Management (CRM) system or cases related to pharmacy benefits within the grievances and Complaint Tracking Module (CTM).

ESSENTIAL FUNCTIONS:

* Ensure that all initiative implementations are properly scoped, documented, and completed within the agreed timelines, and report the status of these initiatives to management.
* Monitor the volume of calls made on an individual and group level to ensure compliance with established productivity metrics and track the resolution time for referrals concerning complaints, grievances, and CTMs related to medications.
* Evaluate specific operational metrics, reports, and dashboards to assess the performance of personnel assigned to the unit and ensure they meet the established indicators, which include, but are not limited to, Assigned Itinerary Compliance and adherence to work schedules, ensuring proper distribution of resources during Call Center hours of operation and meet the quality measure goals. Based on the analysis performed, provide recommendations to the management regarding itinerary adjustments and schedule changes.
* Reports to the management operational metrics of initiatives worked, including the number of interventions/calls completed, calls resulting in a pharmacy claim, and calls to be made to complete the tasks.
* Develop a dashboard to monitor the turnaround time (TaT) and trends for referrals to the pharmacy department from the CRM system or cases related to pharmacy benefits within the grievances and CTM.
* Request and distribute Target Member List (TML) for Interactive Voice Response (IVR) and Short Message Service (SMS) for MCS and Global Health.
* Prepare presentations for interdepartmental meetings, focusing on the metrics from the Clinical Interventions Unit (CIU) that affect STARS scores and ratings.
* Collaborates on the development and deployment of Quality program initiatives with the Pharmacy Quality Program (PQP) of community pharmacies and initiatives with other providers.
* Ensure that personnel in interventions maximize the use of work tools by the service and quality standards established by the department, such as Average Handle Time, Not Ready, and Park Time, among others.
* Addresses situations reported by the vendors, participates in discussions and reports on topics related to CIU Live Call/IVR initiatives.
* Analyze reports in the vendor platform to develop initiatives to mitigate challenges for members to be adherent to their treatments; present and implement leadership on initiatives that support meeting adherence, Statin Use in Persons with Diabetes (SUPD), Statin Therapy for Patients with Cardiovascular Disease (SPC), Concurrent Use of Opioids and Benzodiazepines, and polypharmacy goals.
* Analyze calls and IVR dispositions to optimize outreach and successful attempts and ensure that the call books include all the necessary elements for interventions.
* 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 areas related to Natural Sciences and/or Business Administration. At least three (3) years of experience in Pharmacy data management and analysis, process improvement, and/or functions related to STARS measurement and rating in the healthcare industry.

OR

Education and Experience: Associate's Degree in Pharmacy Technician. At least four (4) years of experience in Pharmacy data
management and analysis, process improvement, and/or functions related to STARS measurement and rating in the healthcare industry.

"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 Medicare Stars Rating Program requirements 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"