Pharmacy Benefits Specialist

🔥 18 hours ago

🦞 Maine – Remote

🦞 Maine – Remote

💵 $25 - $31 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

👩‍👩‍👧‍👦 Human Resources (HR)

👻 Ghost score 0%

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Martin's Point Health Care

WebsiteLinkedInAll Job Openings

501 - 1000 employees

🛡️ Insurance

📦 Logistics

💼 Consulting

Insurance • Logistics • Consulting

Martin's Point Health Care is a healthcare organization committed to serving its local communities through high-quality primary and specialty care services. The organization places a strong emphasis on creating a positive workplace culture, recognizing employee contributions, and fostering workforce diversity. Martin's Point Health Care offers a range of career opportunities across various departments, from healthcare providers to corporate roles, and supports employee growth through competitive compensation, development programs, and generous perks. Additionally, the company is recognized for its community impact efforts, raising significant funds for community organizations and encouraging employee volunteerism.

📋 Description

• Coordinate activities between MPHC and the Third-Party Administrator and Pharmacy Benefit Manager (PBM) • Support pharmacy benefit program initiatives and ensure contractual pharmacy benefit and reporting requirements are met • Monitor channels for pharmacy program benefit changes and alert appropriate individuals • Document and triage plan pharmacy benefit-related calls • Enter prior authorizations into PBM/pharmacy systems and ensure plan design accuracy • Serve as USFHP Pharmacy Guidance subject matter expert • Participate in system configuration and end-to-end testing during implementation or benefit changes • Provide quality assurance and verify coding and plan setup • Train pharmacy and plan staff on PBM and pharmacy system functionality • Develop and update training materials, job aids, FAQs, and provider education materials • Develop corrective action plans for identified plan design problems • Complete special projects, reports, records, and files • Develop procedures and reference materials • Review and follow up on DoD fatal error reports • Coordinate eligibility-related updates in Pharmacy and PBM systems • Develop and maintain workflows for USFHP member overrides • Coordinate consistent procedures for customer/member service calls with the PBM • Research and coordinate responses to member complaints • Analyze pharmacy utilization trends and drive cost-saving initiatives • Support CMS, DoD, NCQA, and DHA audits • Support pharmacy quality improvement initiatives and performance measures, including HEDIS® and Medicare Star Ratings • Collaborate on NCQA accreditation and reaccreditation activities • Participate in annual Medicare Part D plan year implementation, including benefit configuration, UAT, and validation • Back up the Medicare Part D Specialist during absences or high-volume periods • Demonstrate the organization’s mission, vision, and core values

🎯 Requirements

• Associate’s degree or combination of education and relevant experience • 2+ years of administrative, business or other relevant experience required • Healthcare benefit or Pharmacy Technician experience preferred • Knowledge of medical terminology, generic/brand name drugs • Knowledge of PBM third party billing • Excellent customer services skills • Effective written, verbal, and interpersonal communication skills • Solid analytical skills • Strong organizational skills; ability to prioritize and multi-task while maintaining focus on objectives • Strong interpersonal skills and ability to collaborate with internal and external clients • Strong mathematical ability • Ability to reconcile financial reports and data • Ability to function independently with sound judgment in decision making • Ability to take appropriate initiative while soliciting input/advice appropriately • Ability to handle confidential and sensitive information in a discreet and professional manner • This position is not eligible for immigration sponsorship

🏖️ Benefits

• Additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan • Equal opportunity/affirmative action employer • Reasonable accommodations for applicants and employees with disabilities