Medi-Cal Pharmacy Program Specialist

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  • 18-00184
  • Full Time/Contract
  • Pharmacy
  • Rancho Cucamonga, CA
Job Description
CLIENT COMPANY OVERVIEW
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company to Work For, "Favorite Training Program, and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.

JOB TITLE
Medicare PHARMACY PROGRAM SPECIALIST

JOB DESCRIPTION
Under the direction of the Medicare Pharmacy Program Specialist Supervisor, the Medicare Pharmacy Program Specialist is responsible for the technical management of Medicare Part D Coverage Determination and Exception requests.  The Medicare Pharmacy Program Specialist must demonstrate knowledge of CMS regulations, Prior Authorization criteria, policies and resources in order to make accurate and appropriate decisions. The Medicare Pharmacy Program Specialist is dedicated to providing the best care to Company Dual Choice Members and ensuring the Medicare Pharmacy Team remains in compliance with CMS regulations and guidance

JOB DUTIES

  • Technical data field review of Medicare Part D Coverage Determination and Exception requests based on CMS approved Prior Authorization criteria, CMS Medicare Part D regulations, and process guidelines.
  • Contact providers by telephone or fax to request additional medical information for completion of Coverage Determination requests including daily follow up on pended cases as required by CMS.
  • Timely and accurate effectuation of approved medications in Argus, Company’s Pharmacy Benefit Management company (PBM).
  • Complete Member verbal outreach via phone on Medicare Part D Coverage Determination and Exception request in an effort to notify Members of Approval or Denial decisions in the timeliest manner possible.
  • Continual review of Medicare Chapter 18 and Medicare Chapter 6 in order to remain current in regards to all CMS regulations regarding Medicare Part D Coverage Determination and Exception requests.
  • Technical data field review of Organizational Determination requests for Medicare Part B covered medications, Durable Medical Equipment, and Diabetic Supplies.
  • Maintain a high standard in relation to timeliness and quality as well as a drive to not just meet, but exceed the requirements set forth by CMS.
  • Review and complete proactive renewal requests for expiring Medicare Coverage Determinations and Exceptions as part of the Customer Driven (CD) Project to ensure continuity and reduce delay in care.
  • Assist with incoming phone calls related to the Medicare line of business via the Medicare Pharmacy phone queue as needed to maintain the Medicare Pharmacy Service Level Agreement (SLA).
  • Manage and respond to CRM tasks submitted from other internal departments in regards Medicare pharmacy processing issues.
  • Communicate with Pharmacies and Providers regarding issues related to Company Dual Choice formulary, Coverage Determination submission, Prior Authorization criteria, or pharmacy policy and procedures.
  • Interface with Argus, Company’s pharmacy benefit management company, when necessary regarding on-line billing and point of sale issues.
  • Assist in review of pharmacy related discharge orders or request and coordination with specialty pharmacy providers.
  • Assist in review of members’ medical care.  Coordinate care with internal departments (UM, MSR, CM, BH, etc.) or external sources to provide better quality of care.
  • Provide weekend coverage (Sat-Sun) on a rotation basis with all Medicare Pharmacy Program Specialists in order to ensure continuous compliance with CMS timeframes and regulations.
  • Active participation in Managing for Daily Improvement (MDI) huddles and experiments as well as other LEAN activities and events in order to foster and promote continuous process improvement within the Medicare Team, the Pharmaceutical Services Department, and Company as a whole.
  • Participate in Medical Services Staff Meetings or other activities as needed.
  • Assist the Medicare Pharmacy team with any additional duties as required to ensure successful plan operations.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in Company's policies and procedures relating to HIPAA compliance.
  • Committed to striving for the highest level of quality, both in work completed and care provided to Company Members. Seeks not to just meet but exceed CMS regulations as well as the standards set forth through Company’s strategic goals.

 
 
SKILLS & QUALIFICATIONS

  • California State Board of Pharmacy, Pharmacy Technician. Associate, Bachelor of Arts or Bachelor of Science degree from accredited college preferred.
  • Three (3) or more years of experience as a pharmacy technician, preferably in HMO or Managed Care setting with at least 1 year of Prior Authorization processing.  Medicare Part D experience preferred.
  • Microsoft Office products. Ability to efficiently navigate within multiple computer systems. Type minimum 35 wpm.  Excellent organizational, written and verbal communication, multi-tasking skills.  Highly motivated, with good interpersonal skills, able to work independently as well as in a team environment.  Display the ability to adapt and perform duties efficiently whenever unexpected changes arise.

 
COMPENSATION | POSITION CLASSIFICATION

  • $18.03/hr.
  • Full-Time | Contract Assignment

 
 


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