Pharmacy Benefit Quality Specialist

US-IA-Des Moines
Job ID
212776
Category
Clinical/Provider Support
Requires Non-Compete?
No

Job Summary

About Us: We’re Wellmark’s Pharmacy Services team, and we’re accountable for oversight of all clinical and operational facets of the Wellmark pharmacy program. This includes Wellmark's Pharmacy and Therapeutics Committee, which is responsible for guiding clinical decisions which are the foundations of a diverse pharmacy product portfolio. In addition, we oversee vendors and utilization management programs in order to successfully contain rising drug costs.

 

About The Role: We're hiring a brand new Pharmacy Benefit Quality Specialist will serve as a key quality assurance resource in ensuring that pharmacy programming has been set-up accurately by the PBM. This individual will provide quality assurance, testing related to claim adjudication and plan set-up, and will ensure all coding has been done appropriately, while also reviewing system generated outputs to validate outcomes. Additionally, this individual will provide oversight of all PBM data interfaces, ensuring control points are in place to confirm delivery and receipt of files, accuracy for those files, and that mapping of data fields is correct.

 

Ideal candidates possess knowledge of pharmacy operations and UM tools, experience with reporting, data integrity, and testing, and have strong critical thinking skills. (Microsoft Excel is a must; SharePoint is a preferred.) They’re effective communicators, naturally inquisitive, and are able to build strong stakeholder relationships. Sound like a fit? Consider applying today!

 

Minimum Qualifications Required (all must be met to be considered)

  • Associate’s Degree or direct and applicable work experience.
  • 2+ years of related experience in managed care, health care, pharmacy, or PBM, including:
    • Knowledge of UM tools (e.g., formulary, prior authorization, step therapy), Medi-Span files, and claims processing.
    • Experience with data reporting, analysis and/or interpretation of data to identify irregularities for resolution.
    • Analysis of systems/processes and user acceptance testing. Demonstrated ability to define business needs and requirements, develop test cases, etc.
  • Natural curiosity with effective problem solving, critical thinking, and research skills. Ability to understand and investigate issues relating to overall system/data integrity, as well as define and implement appropriate resolutions.
  • Quality assurance focused with demonstrated commitment to accuracy and attention to detail.
  • Strong written and verbal communications skills with the ability to clearly and concisely communicate complex concepts with internal and external stakeholders.
  • Strong interpersonal skills with the ability to build relationships of collaboration and trust with different business areas. Viewed as a subject matter expert and go-to resource.
  • Proficiency with Microsoft Office, including Excel; use of pivot tables, charts, and formulas is preferred. Technical aptitude to learn new software quickly.
  • Self-starter with strong organizational skills and the ability to multi-task priorities in a fast-paced, dynamic environment. Flexible and adaptable to change.

Hiring Specifications Preferred

  • Associate’s Degree.
  • Certified Pharmacy Technician.
  • SharePoint experience.

Job Accountabilities

a. Conduct pharmacy benefit quality reviews for plan designs. Will include pulling reports, interpreting benefits, claims testing and reviewing web applications to ensure that the PBM configurations are accurate and complete.

b. Responsible for reviewing all PBM coding, including formulary and plan set-ups, network coding - including not only validation of all programming requests sent to the PBM but also constant coding updates performed by the PBM relating to the plan set-ups and configurations.

c. Serve as a primary point of contact for the PBM regarding coding issues identified. Ensure the appropriate remediation is conducted.

d. Research and provide detailed recommendations on ways to improve or enhance team processes including testing methods, documentation, and training opportunities.

e. Create comprehensive pharmacy configuration test plans for unique or complex benefit designs; including supporting standard designs during peak season. Identify, analyze, document and re-test system defects found during test execution. Escalate potential issues when necessary and effectively communicate with key stakeholders.

f. Work with and assist team members during the research and resolution of potential issues.

g. Participate in cross-functional projects and project test plan set-up; participate in process improvement initiatives as necessary.

h. Other duties as assigned.

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