Description and Requirements
Reporting to the AVP, Pharmacy Benefit Operations, the Manager will be mainly responsible for implementing, monitoring and evaluating the successful launch of various upcoming Legislative requirements across all Lines of Business. This position will play a critical role, in collaboration with Enrollment & Billing, in executing implementation and ongoing monitoring efforts related to the Medicare Prescription Payment Plan (M3P). This includes, but not limited to, policies and procedures development, pharmacy claims monitoring and member invoice reconciliation, vendor oversight, and providing subject matter expertise input and training across the organization to ensure an optimal overall member experience. The ideal candidate has experience leading cross-functional teams to meet project timelines and has the skills and ability to present to all levels of Leadership.
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Duties & Responsibilities:
- Monitors all State & Federal regulations and program changes impacting pharmacy benefits and ensures timely implementation and/or compliance with regulations to meet or exceed audit standards.
- Responsible for new programs and initiatives assigned to meet organization operations, regulatory, compliance and strategic goals. (e.g.M3P)
- Responsible for preparing, reviewing, analyzing and reporting initiative metrics in order to gauge program success/failures and opportunities for improvement
- Performs operational oversight of M3P vendor and PBM (Pharmacy Benefit Manager) data and activities.
- Develops strategies to optimize pharmacy benefits, pharmacy operations and member experience across all lines of business.
- Assists in regulatory and compliance audits for all plans
- Additional duties as necessary
Minimum Qualifications:
- Bachelor's degree from an accredited institution
- Knowledge of regulations of the Centers for Medicare and Medicaid Services and the New York State Department of Health
- Demonstrated critical thinking and problem-solving skills.
- Ability to lead large and small working meetings.
- Outstanding communicator with excellent verbal, written and presentation skills.
- PC Skills with Microsoft Word, PowerPoint (creating presentations and slides), Excel (Pivot tables), Access (creating databases), Visio (creating workflow charts) and Adobe Acrobat.
Preferred Qualifications:
- Knowledge of billing practices in the medical and pharmacy benefits.
- Experience with pharmacy benefit management oversight including maintaining policies and procedures related to benefits administration, claims adjudication and utilization management processes.
- Demonstrate effective communication and presentation skills in small and large groups
- Demonstrate ability to initiate, prioritize, organize and manage multiple priorities with acute attention to detail
Compliance & Regulatory Responsibilities: Noted above
License/Certification: N/A
Hiring Range:
- Greater New York City Area (NY, NJ, CT residents): $100,900 - $145,775
- All Other Locations (within approved locations): $86,500 - $128,690
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.