Medical Mutual · 5 days ago
Medicare Pharmacy Specialist
United States
Full-time
Remote
Mid, Senior Level
2+ years expMedical Mutual is the oldest and one of the largest health insurance companies based in Ohio, providing peace of mind to over 1.2 million members. They are seeking a Medicare Pharmacy Specialist to support the operations and compliant administration of the Medicare Pharmacy program, overseeing Pharmacy Benefit Manager compliance and acting as a liaison between internal departments and vendors.
Health CareHealth InsuranceInsuranceLife Insurance
Responsibilities
Supports oversight and monitoring of assigned functional area(s) including, but not limited to, PBM and Medical Drug Management (MDM) vendors, and operations compliance of formulary administration, claims processing, transition policy, Prescription Drug Event (PDEs), Explanation of Benefits (EOBs), Coverage Determinations and Exceptions, Organizational Determinations, and other Part D operational requirements
Handles escalated issues and projects primarily related to assigned functional area(s) (e.g., claims, compliance concerns, and coding errors)
Meets regularly with PBM and Utilization Management (UM) vendors to ensure CMS and contractual compliance with all pharmacy/medical drug policies and processes
Participates in internal and external audits of the Part D and Part C programs including but not limited to assigned functional area(s)
Provides subject matter expertise to internal staff to support Part D regulations, operational and submission requirements for the following items: Coverage Gap Discount, Appeals, Grievances, Medicare Marketing material, Quality and STARS initiatives, Medicare Application & Bid process, Employer Group Waiver Plan (EGWP) Request for Proposal (RFP) & Implementation, Benefit Testing, and Medicare Required Reporting
Supports activities to foster CMS compliance awareness
Performs other duties as assigned
Qualification
Required
Bachelor's degree in business or health care administration, pharmacy, or related field
In lieu of degree, may consider equivalent combination of education/training and experience
2 years of experience in health plan or PBM operations, which includes Medicare Part D
Knowledge of Part D, managed care, and the Medicare program
Knowledge of National Committee for Quality Assurance (NCQA) or general accreditation standards
Knowledge of Medicare appeal and grievance processes and guidelines
Intermediate Microsoft Office, database reporting and PBM systems skills
Preferred
Medicare Part C (medical drug) experience
Pharmacy technician certification
Benefits
Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
Career development programs and classes.
Mentoring and coaching to help you advance in your career.
Tuition reimbursement up to $5,250 per year, the IRS maximum.
Diverse, inclusive and welcoming culture with Business Resource Groups.
Company
Medical Mutual
Medical Mutual Provides and administers health benefits for citizens in Ohio.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Annette Terrien Hill
RNI Chief Operating Officer
Christopher Donovan
Executive Vice President, Chief Data and Information Officer
Recent News
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