Pharmacy Benefits Specialist

This is a fully remote position, open to applicants in Maine.

📋 Description

• Facilitate collaboration between MPHC, the Third-Party Administrator, and the Pharmacy Benefit Manager (PBM).

• Assist in pharmacy benefit program initiatives, ensuring compliance with contractual pharmacy benefits and reporting obligations.

• Track updates on pharmacy program benefits and notify relevant parties.

• Record and manage pharmacy benefit-related inquiries.

• Input prior authorizations into PBM/pharmacy systems and verify accuracy in plan design.

• Act as the subject matter expert for USFHP Pharmacy Guidance.

• Engage in system configuration and comprehensive testing during implementation or benefit modifications.

• Ensure quality assurance by verifying coding and plan setups.

• Educate pharmacy and plan personnel on PBM and pharmacy system functionalities.

• Create and revise training materials, job aids, FAQs, and educational resources for providers.

• Formulate corrective action plans for identified issues in plan design.

• Complete special projects, reports, and maintain records and files.

• Develop procedures and reference materials.

• Review and follow up on Department of Defense (DoD) fatal error reports.

• Oversee eligibility updates in Pharmacy and PBM systems.

• Create and maintain workflows for USFHP member overrides.

• Ensure consistent procedures for customer/member service calls in coordination with the PBM.

• Investigate and coordinate responses to member complaints.

• Analyze trends in pharmacy utilization and implement cost-saving strategies.

• Support audits from CMS, DoD, NCQA, and DHA.

• Assist in pharmacy quality improvement initiatives and performance measures, including HEDIS® and Medicare Star Ratings.

• Collaborate on activities for NCQA accreditation and reaccreditation.

• Participate in the annual implementation of the Medicare Part D plan year, including benefit configuration, user acceptance testing (UAT), and validation.

• Provide backup support for the Medicare Part D Specialist during absences or periods of high volume.

• Embody the organization’s mission, vision, and core values.

⛳️ Requirements

• Associate’s degree or a combination of education and relevant experience.

• Minimum of 2 years of administrative, business, or other pertinent experience.

• Preferred experience in healthcare benefits or as a Pharmacy Technician.

• Familiarity with medical terminology, including generic and brand name drugs.

• Understanding of PBM third-party billing processes.

• Exceptional customer service skills.

• Strong written, verbal, and interpersonal communication abilities.

• Competent analytical skills.

• Excellent organizational capabilities; able to prioritize and manage multiple tasks while maintaining focus on objectives.

• Strong interpersonal abilities and a knack for collaborating with both internal and external clients.

• Proficient mathematical skills.

• Capability to reconcile financial reports and data accurately.

• Ability to work independently with sound judgment in decision-making.

• Initiative to take appropriate actions while seeking input and advice when necessary.

• Capacity to handle confidential and sensitive information professionally and discreetly.

• This position does not qualify for immigration sponsorship.

🏝️ Benefits

• Additional compensation opportunities, including incentive or commission-based programs, subject to the relevant plan's terms.

• Equal opportunity/affirmative action employer.

• Reasonable accommodations for applicants and employees with disabilities.