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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Support all aspects of the pharmacy benefit and reporting while working with Pharmacy leadership on designing, implementing, and coordinating pharmacy program initiatives. Support the pharmacy benefit and work with the Pharmacy team on implementing, and coordinating pharmacy initiatives, including compliance and 5-Star goals. Key areas of focus include Pharmacy Benefit Management (PBM) operations, utilization management platform operations, Pharmacy/data analytics, and business analysis and process improvement.
Essential Responsibilities:
Provide oversight and quality assurance to ensure accurate set up of pharmacy benefit designs, formulary coding, network coding reporting, drug pricing, through PBM configuration testing and claims analysis.
Collaborate with Sales, Product Development and Pharmacy teams to ensure accurate and optimal pharmacy benefit designs and initiatives.
Support Sales team by generating and analyzing claims data, formulary comparisons, and projections for new and existing groups.
Manage interface between vendor/consultant/client to ensure efficient coordination and implementation of coding, including appropriate oversight and monitoring of all PBM operations, data interfaces, and external communications.
Support formulary administrators and leadership on initiatives, tasks and projects related to all aspects of the plans' pharmacy benefit for all lines of business (Medicare, Medicaid, Commercial).
Perform ongoing drug and claim configuration setup and testing to ensure accuracy of point of service adjudication.
Provide claims research, analysis, and support during internal and external audits
Research, troubleshoot and resolve claims issues, along with review and documentation of service warranties.
Generate and analyze reports for new and transitioning groups.
Develop Pharmacy department policies and procedures as applicable and regular maintenance to reflect new best practices and guidance.
Organize, document, and support departmental performance dashboards.
Track and record drugs at launch for clinicians to make potential coverage and formulary decisions.
Support ongoing communication efforts including member, pharmacy and provider notifications.
Build reports in internal reporting software and performing accurate and complete data extraction from our data warehouse to support demands of pharmacy reporting, analysis and projections.
Analyze medical and pharmacy claims to identify cost savings opportunities and process improvements and facilitate cross-departmental prioritization of pharmacy initiatives.
Present complex data, analysis and findings to internal and external teams in a way that is clear and understandable.
Participate in special projects and committees.
Supporting Responsibilities:
Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.
SUCCESS PROFILE
Work Experience: Minimum of five years of experience within a healthcare field. Preference for experience within managed care or pharmacy. Preference for experience with Medicare Star ratings, Medicaid quality initiatives, and NCQA standards. Preference for experience with Pharmacy benefit managers and project management.
Education, Certificates, Licenses: Bachelor's degree required, with preference on degree in public health, healthcare related, mathematics, statistics, data science, or similar research related field, or equivalent years of relevant experience in lieu of degree. Strong preference for certification in data software such as RxClaim, SQL, SAS, excel, tableau.
Knowledge: Strong computer skills. Strong skills within Microsoft application software including Word and Excel. Excellent verbal and business writing skills. Excellent public relations skills. Good understanding of Medical Terminology required. Requires ability to define and prioritize problems and manage workload without direct supervision. Ability to work within tight timeframes and meet strict deadlines. Ability to gain in-depth knowledge of the RxClaim PBM software. Ability to perform claims analysis to find complex problems and identifies solutions. Coding and analytics knowledge required. SQL experience preferred.
Competencies
Adaptability
Building Customer Loyalty
Building Strategic Work Relationships
Building Trust
Continuous Improvement
Contributing to Team Success
Planning and Organizing
Work Standards
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Skills:
Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork
Our Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for customer service.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internally and externally.
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
