Responsible for pharmacy benefit services operations for the Medicare line of business. Operate as a Project Manager accountable for managing processes related to PBM Performance, Part D adjudication of benefits, and pharmacy audits. Function as a subject matter expert on Medicare Prescription Drug Coverage.
Medicare Part D subject matter expert responsible for conveying applicable CMS regulatory guidance and expectations to staff within the pharmacy department. Consult with compliance divisions to provide strategic enterprise support. Maintain cross-functional relationships with Sales, Account Management, Government Programs, IS/IT, Internal Audit, and other applicable divisions to ensure compliant and accurate administration of pharmacy benefits across delivery systems.
Manage Part D benefit implementation and provide post-project oversight with the contracted PBM. Ensure pharmacy projects are completed while maintaining a strong focus on Medicare Part D compliance. Represent Pharmacy Health Plan in the role of a Medicare Subject Matter Expert by providing current operational state and conveying future needs. Update departmental policies as needed.
Facilitate cross-functional efforts throughout the enterprise to ensure optimal 5-star Medicare measures. Support annual readiness, maintain industry knowledge, and provide in-depth analysis to guarantee proper support for Medicare Programs. Manage pharmacy audits as they are received.
Work with leadership to manage the PBM relationship. Ensure Medicare Part D related contract terms are met. Address escalations with PBM staff to ensure favorable resolution. Work closely with business partners to facilitate prime client/vendor rapport while identifying cost saving opportunities for the enterprise.