- Leadership
- Selects, develops, mentors, and retains engaged and high-performing staff. Provides coaching, development opportunities, and performance management.
- Fosters a culture of accountability, collaboration, and continuous improvement.
- Manages relationships with vendors and...
- Participate in the development, implementation, and measurement of clinical practice guidelines and quality programs, including drug-based (prescribing) guidelines, and disease-state-based guidelines.
- Conduct analysis of medications for Quartz Drug Formulary to include critical evaluation of drug literature and FDA data, consultation with experts, consensus building amongst practitioners, analysis of impact on relevant populations, consideration of utilization management tools available and incorporation of economic data.
- Participate in the...
Pharmacy Specialist, Government Program Operations Role:
- Oversee the administration and implementation of pharmacy benefit programs, P&T Committee decisions, and benefit changes, including maintenance and updating of the formulary database, ensuring that medication lists are current and reflect the latest clinical guidelines and policy changes, and review/approval of testing by PBM and other vendors.
- Review pharmacy claims for accuracy, ensuring compliance with benefits policy guidelines and formulary requirements and...
- Investigate other insurance information to coordinate benefits for claims processing
- Direct contact with members, CMS, or other health plans via telephone, letters, email, or portal submissions to obtain/verify other insurance information
- Determine primacy based on the other insurance obtained and confirm automatic filing order (AFO) is accurate
- Update Health Link with the other insurance information and ensure AFO is...
- Financial Performance & Payment Integrity Oversight
- Oversees the financial and key performance indicators related to pre-pay integrity services, post-pay integrity services, premium revenue services, and remediation initiatives to ensure financial and key performance targets are met.
-
- Partners with the business to define and document processes and software requirements for technology initiatives.
- Serves as the primary liaison between business teams, development teams, vendors, and architects to ensure alignment from concept through delivery.
-
