This position is responsible for coordination and oversight of operational activities that support the delegated business relationships with UCare’s Pharmacy Benefit Manager (PBM) and Specialty pharmacy provider for all products. Serve as a liaison between the PBM / Specialty Provider and UCare internal departments ensuring day to day and strategic operational goals are met. Develop and maintain department policies, procedures and work instructions. Support the clinical pharmacy team as appropriate on cross departmental issues and projects. Specific duties and responsibilities include:
Maintain an expert understanding of UCare products, benefits, and internal operations. Facilitate and oversee pharmacy related cross-departmental activities with the PBM to ensure that UCare operational changes do not adversely affect PBM processing, and PBM issues / changes are communicated and addressed appropriately within affected UCare departments. Facilitate communication to ensure PBM fully understands UCare business requirements.
Collaborate with Pharmacy leadership team to develop and manage strategic department goals and objectives within the pharmacy department.
Oversee operational team working on activities that support day to day operations within UCare and our delegated pharmacy partners; as well as ensure operational goals of the department are met.
Collaborate with the Compliance Department to monitor PBM regulatory compliance. Work with the Compliance and Government Relations Departments to ensure that regulatory changes are clearly understood by the PBM and applicable UCare staff.
Maintain a calendar that identifies key activities and due dates, including: regulatory reporting to CMS, standard audits, updates to all pharmacy marketing materials and member / provider communications; and other key processing deadlines including DHS or MDH.
Support Compliance Department efforts related to delegation oversight and fraud, waste, and abuse audits.
Lead testing of PBM and applicable UCare systems related to benefit and formulary changes across all market segments. Testing includes but is not limited to claims processing, web portals, member materials, clinical programs, and file transfers.
Maintain UCare Pharmacy Department policies and procedures. Responsible for ensuring they meet UCare regulatory and business needs.
Ensure the needs of clinical pharmacy management are being met in regards to formulary, utilization management processes, and medication therapy management.
Experience working in the managed care industry, with significant experience in health care operations or pharmacy operations management. PBM operations, clinical or account management experience. Experience with government programs and compliance pertaining to pharmacy practice. Knowledge of Medicare, State Public Programs and HealthCare Exchange rules and regulations.
Bachelor’s degree in health care management, business administration, or related field; demonstrated work experience may be considered in lieu of a degree.
At UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities.
WORKING AT ...UCARE
Working at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization – from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do.