The Medicare Pharmacist manages Medicare operational and clinical pharmacy processes for the Health Choice beneficiaries by assisting in the maintenance of Medicare formulary and pharmacy benefit. The Medicare Pharmacist maintains and create audit protocols for the Medicare pharmacy benefit and formulary activities (internal and PBM delegated activities), reviewing requests for prescription drug services and complex member cases, and participating in efforts to improve clinical program quality and pharmacy performance measures (e.g. Medicare Stars, Patient Safety, Level 3 Narcotic DUR, MTMP, etc. ). The Medicare Pharmacist will educate appropriate Health Choice staff on specific Medicare pharmacy topics, processes and documents as well as assist the Pharmacy Director as needed.
Develop, implement, and enforce Medicare Part D operations that are documented with desktop procedures. (e.g. formulary maintenance and member transitions, drug prices submissions, pharmacy coordination of benefits, Fraud, waste and abuse prevention, Troop accumulation, PDE oversight)
Work closely with PBM vendor related to Part D pharmacy benefit operations.
Collaborate with Pharmacy Director and PBM P&T Committee on Medicare formulary administration activities
Maintain accurate Health Choice Generations prescription drug formulary and related documents, as well as other Part D materials on the website.
Collaborate and communicate with interdepartmental staff and pharmacy and prescribers providers
Maintain Pharmacy Medicare Part D Policies and Procedures in accordance with CMS guidelines and requirements and audit requirements.
Create, implement and maintain audit protocols for Part D functions which include but are not limited to monthly formulary documents, Part D claims processing (PDE, Retro-LICS, member reimbursements) member transitions and explanation of benefits, plan finder, ICD/RD clinical review, formulary change notifications and vendor P&T functions.
Respond to Medicare Part D requests for information and audits. Audit response includes CMS onsite and Desktop audits (e.g. Transition audit, reject audit, Hospice drug audit, Level 3 DUR audits).
Pharmacy degree from an accredited College of Pharmacy, PharmD preferred
At least five (5) years of practice experience with a health plan pharmacy service, managed care environment, and / or retail or hospital pharmacy service
At least two (2) years of practice experience in Medicare Part D operations
At least two (2) years of practice experience in developing policies and procedures, desktops, and audit protocols
Arizona or Utah state Pharmacy license in good standing
Current Arizona or Utah driver's license, reliable transportation, and current insurance coverage required.
Job Reference #: 1803972