Pharmacy Quality & Resolution Specialist

Job Description

Job Description

Pharmacy Quality & Resolution Specialist

Location: Birmingham, Alabama

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Healthcare Reimbursement Account
• Paid Parental Leave
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

See more about the benefits of working at Viva Health -

Job Description

The Pharmacy Quality & Resolution Specialist is responsible for ensuring the accuracy and efficiency of day-to-day operations of VIVA HEALTH’S pharmacy programs for all lines of business. This individual is responsible for coordinating with the contracted Pharmacy Benefit Manager (PBM) or vendor, assisting local pharmacies, assisting with regulatory agency requirements, ensuring utilization and eligibility issues are monitored and addressed, and handling escalated billing and claims inquiries related to drug coverage and benefits.

Key Responsibilities

• Provide Pharmacy department support of both external customers and our internal stakeholders by acting as a subject matter expert for complex and escalated drug coverage and benefit related issues. This includes direct outreach to internal departments and external customers such as members, pharmacies, provider offices, and decision-makers at employer groups to ensure smooth operations of pharmacy programs.
• Thoroughly research issues and take appropriate action to resolve cases in a timely manner according to the quality standard. Resolve issues and communicate outcomes in a clear and concise manner by outreach to members, providers, or impacted internal, and external customers.
• Assist the Medication Quality Team by scheduling Comprehensive Medications Reviews (CMR), work to proactively renew expiring prior authorizations (PAs), making member outreach calls to help educate members and improve member medication adherence and other related activities.
• Assist with program and benefit change implementations for Medicare and Commercial business and assist with quality assurance reviews of such changes and programs.
• Monitor, review, and analyze daily reject reports from the plan’s PBM according to Centers for Medicare and Medicaid Services (CMS) guidelines.
• Analyze and follow up on identified issues to ensure the appropriate processing of Part B vs. D drugs and maintain the internal and external Hospice and End-Stage Renal Disease (ERSD) reports according to CMS guidelines.
• Audit plan benefits, formulary updates, and any changes that the PBM implements.

REQUIRED QUALIFICATIONS :

• High School Diploma or GED
• At least 3 years of experience with HMO/PPO/Medicare, pharmacy benefits management, retail pharmacy, long term care pharmacy, or hospital pharmacy
• Current Pharmacy Technician License in good standing with the Alabama State Board of Pharmacy
• CPhT (Certified Pharmacy Technician) from the Pharmacy Technician Certification Board (PTCB) or the National Healthcare Association
• Demonstrate excellent customer service skills through written and verbal communication
• Proficient in the Microsoft Office suite of products including Word, Excel, Access, and PowerPoint

PREFERRED QUALIFICATIONS:

• At least two years of college