Two to five years of Retail Pharmacy, Health Plan, and/or PBM (pharmacy benefit manager) experience is preferred; knowledge in the field of pharmacy is expected.
Expert-level proficiency with Microsoft applications, including Excel, Word, and PowerPoint, and the ability to create reports and manipulate data sets.
Ability to work independently with minimal supervision.
Ability to communicate clearly and effectively, both verbally and in writing.
Ability to treat confidential information appropriately and adhere to policies, procedures, rules, and regulations while conducting oneself professionally and sensitively toward the target population.
Ability to follow applicable government regulations, including HIPAA.
Ability to relate to and communicate effectively with staff, participants, and families.
Ability to apply a customer service approach to problem-solving and operations.
Ability to meet the stated physical requirements, including standing up to six hours daily; sitting for six to eight consecutive hours; lifting, pushing, or pulling up to 50 pounds; bending or squatting; safely using stairs and walking to work areas; demonstrating agility and fine motor skills to operate equipment and type; visually reading and accurately documenting information; listening attentively and speaking clearly; and applying sound judgment and analysis.
Responsibilities
Review the daily rejected claim report.
Contact providers and pharmacies to inform them of formulary alternatives when available, explain how to submit prior authorization requests, and follow up on cases when necessary.
Assist dispensing pharmacies with claim issues.
Analyze and identify inappropriately paid and denied claims with financial implications for the pharmacy budget and potential financial actions from CMS.
Serve as a pharmacy liaison between the clinical pharmacy department and other internal departments; answer or redirect internal and external pharmacy questions, provide research and analysis as needed, and follow through to resolution.
Review transition-fill reports to ensure transition fills are appropriate and assist providers with formulary alternative switches.
Generate and distribute reports to the Pharmacy Management team and other programs as needed; upload PBM reports to Pharmacy SharePoint sites and keep the documents organized and complete.
Support the pharmacy team on clinical programs, including care coordination with pharmacies and providers, record keeping and tracking, and reporting.
Perform additional functions as needed for pharmacy department operations.
Perform other related duties as required.
Adhere to Human Resources and Staff Development policies and procedures, including facility and department orientation and mandatory training and education.
Desired Qualifications
A Pharmacy Technician Certification is preferred.
A bachelor's degree is preferred but not required.
Two to five years of Retail Pharmacy, Health Plan, and/or PBM experience is preferred.
Multilingual ability is a plus.
JOB PURPOSE:
The Pharmacy Specialist should have a good understanding of Centers for Medicare and Medicaid Services (CMS) federal regulations and New York State Medicaid regulations related to the pharmacy benefit. The individual will assist with the required delegated oversight and monitoring (OM) functions for the CenterLight PACE program. The OM function has financial implications for the detection of claims processing issues and has a direct impact if a participant is unable to obtain their medications under the required guidelines. The Pharmacy Specialist is a vital part of the pharmacy team, and coordinates care for our participants to ensure medication access.
JOB RESPONSIBILITIES:
Review daily rejected claim report.
Contact providers/pharmacies informing formulary alternatives when available and/or how to submit Prior Authorization requests and follow up on the cases when necessary.
Assist dispensing pharmacies with claim issues.
Analysis and identify inappropriately paid and denied claims that have financial implications both for the pharmacy budget and prevention of financial actions from CMS.
Act as pharmacy liaison between the clinical pharmacy department and other internal departments. Answer or re-direct internal and external questions related to pharmacy; provide supportive research and analysis as needed and follow through to resolution.
Review transition fill a report to ensure transition fills are appropriate and assist provider with formulary alternative switch.
Generate and distribute reports to the Pharmacy Management team and other programs as needed. Upload PBM reports to the Pharmacy SharePoint sites and keeps the document organized and complete.
Provide support to the pharmacy team on different clinical programs, which includes care coordination with pharmacy/providers, record keeping/tracking, and reporting.
Perform additional functions as needed for the operations of the Pharmacy department.
Weekly Hours: 40
Schedule: 8:30 AM - 5:30 PM
QUALIFICATIONS:
Education:
High School Diploma or equivalent required; Pharmacy Technician Certification is preferred; Bachelor’s degree preferred but not required.
Experience
2-5 years of Retail Pharmacy, Health Plan, and/ or PBM (pharmacy benefit manager) experience preferred. Demonstrates knowledge in the field of pharmacy.
Expert level proficiency with Microsoft applications, including use of Excel, Word, and PowerPoint. Able to create reports and manipulate data sets.
Self-motivated, with demonstrated ability to work independently with minimal supervision.
Ability to communicate clearly and effectively, both verbally and in writing.
High level of integrity as demonstrated by 1) appropriate treatment of confidential information, 2) adherence to policies, procedures, rules, and regulations, 3) professional conduct in dealing with persons internal and external to the organization, and 4) sensitivity towards target population.
Multi-lingual a plus.
Other:
Follow all applicable government regulations including HIPAA.
Performs other related duties as required.
Relates to and communicates effectively with staff, participants, and families.
Incorporates a customer service approach to problem-solving and all operations.
Adheres to all Human Resources (HR) and Staff Development policies and procedures, including facility and department orientation and mandatory training and education.
Physical Requirements
Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:
Standing – Duration of up to 6 hours a day.
Sitting/Stationary Positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.
Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job.
Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas.
Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)
Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.
Audio Hearing and Motor Skills (Language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.
Disclaimer:Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.
We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.
Salary Range (Min-Max):
$66,300.00 - $72,000.00
Every application is reviewed by our recruitment team. We do not use AI to make hiring decisions or automatically reject applicants. All employment decisions are based on job-related qualifications and applicable employment laws.