The primary responsibility of this position is to serve as liaison between the pharmacy network, AlohaCare (AC), and AC’s Pharmacy Benefit Manager (PBM) to ensure on-going quality service delivery to AC’s QUEST and Part D pharmacy networks. This involves being the point of contact for pharmacy and physician escalated complaints and close coordination/interface with AC’s PBM, AC Provider Networks, the AC Clinical Operations/Pharmacy Manager, AC Marketing, AC Claims, AC
Customer Service, AC Plan Operations, and various other AC Departments.
Primary Duties and Responsibilities:
Required Competencies and Qualifications:
- Educate Providers and the pharmacy network on AlohaCare’s philosophy, the pharmacy benefits, AC’s Formularies, and the Coverage Determination/Prior Authorization process, which includes presentations to small and large groups.
- Work with AC Depts, network pharmacies and PBM to ensure timely issue resolution.
- Assist pharmacy and physician providers on drug claims related activities and interface with various AC departments and/or the PBM as needed to ensure prompt payment.
- Develop, coordinate internal approval process, and production of pharmacy benefit and formulary management communications for internal and external distribution.
- Develop and maintain the QUEST and Part D pharmacy network directories for internal and external distribution.
- Work with AC Clinical Operations Manager, AC Provider Relations, and/or the PBM to resolve operational issues that affect the pharmacy network and other network Providers.
- Understand AC’s business objectives to assist AC’s Pharmacy Manager in pharmacy contracting, specialty drugs, and other opportunities.
- Review policies and procedures related to pharmacy network management.
- Monitor delegated PBM services related to the pharmacy network.
- Understand and ensure compliance with State, Federal, and Accreditation requirements related to the pharmacy network.
- Assist Provider Relations in educating the non-pharmacy Provider network regarding the pharmacy benefits, AC’s Formularies, and the Pharmacy & Therapeutics Committee process
- Assist Marketing in educating members regarding their pharmacy benefits.
- Upload reports from PBM to specific AlohaCare assignees (i.e. Pricing Files, Rebates, PDE, etc).
- Manage/initiate Ad-Hoc reports as needed for AlohaCare in relation to PBM.
- Manage special projects as assigned.
- Other duties as assigned
Required Education, Licensure or Certification:
- 1 year of experience in retail pharmacy
- Excellent communication skills (written and verbal)
- Strong organizational and time-management skills
- Team player
- Demonstrated professionalism both externally and internally
- Positive work ethic and willingness to go “above and beyond” when necessary
- Able to work with limited supervision
Preferred Competencies and Qualifications:
- College Degree in related field preferred
Additional Job Requirements:
- 1 year of pharmacy network management experience
- 2 years of managed care experience
- Proficient in Word, Excel, PowerPoint, and basic Access data bases desired
- Learn and develop experience in the use of AlohaCare’s information system, QMACS, and AlohaCare’s historical data bases
- Learn and develop experience in the use of Medco Health Solutions Client website and various reporting tools (ExPER
T) as well as the claims and authorization processing platform/system sponsored by the PBM.
- Travel to Neighbor Islands may be needed periodically
AlohaCare - 18 months ago