Clinical Operations Analyst

Profile

Clinical Operations Analyst (Pharmacy)','Full-time','Professional Non-Clinical','Days','Days','80','80','None','None','WASHINGTON-FEDERAL WAY-FEDERAL WAY-HERON BLDG','','!*!SummaryThe Medicare Clinical Operations Analyst is responsible to support the Medicare Pharmacy Services team in compliance operational processes with Medicare Part D guidelines through development of cross-functional department training and tools within the health plan business, supporting the oversight of delegated services provided by the Pharmacy Benefit Manager (PBM), and supporting clinical quality improvement programs offered by Pharmacy Services division.  Acts as secondary subject matter expertise for pharmacy benefit operations for backup of the Pharmacy Benefit Manager (PBM) role on behalf of the health plan internally and externally to organization. Supports the Delegation Oversight team in clinical data oversight and administration of Medicare delegated vendors.Essential Duties and ResponsibilitiesServe as a liaison between pharmacy department and cross-functional areas for process and policy development compliant with Medicare Part D regulations, to include Direct Member Reimbursement (DMR), Part D Coverage levels, Claims Processing, End Stage Renal Disease, Hospice, etc. that impact retroactive pharmacy claims processing. Development of training materials and education of internal cross-functional staff on pharmacy related Medicare Part D topics. Work with internal staff and the PBM to identify, address and resolve operational issues, and assist with the oversight of corrective actions as needed. Support Medicare Quality Improvement related projects and initiatives as needed. Work cross-functionally with clinical and operational business areas to ensure compliance is achieved through collaborative projects as needed. Supports continual development and maintenance of Medicare Part D Policies, Procedures and departmental objectives to achieve corporate goals. Support development and maintenance of Part D member materials including Formularies, Pharmacy Directories, Explanation of Benefits, Transition Letters, Exclusion Letters, etc. to ensure Medicare compliant documents. Performs utilization and vendor invoice reviews to conduct validation analysis of charges billed to the health plan.Provide escalation support of internal and external calls and emails regarding prior authorization, claims processing, formulary, or coverage inquiries for all health plans nationally.Support successful yearly plan implementation with the PBM, to include completion of the Implementation Questionnaires’, coordination of the Group and Member files and final end-to-end testing of groups, member and benefit configuration prior to the go-live date. Conduct independent recurrent monthly oversight of cross-functional and delegated entity operational tasks such as website posting, customer service support, member reimbursement claims and PBM reports.Conduct oversight of the overall PBM pharmacy claims adjudication process to ensure compliance with plan benefits, cost sharing and Medicare Part D requirements.Support oversight of delegated entity generation of Medicare Part D required reporting and the annual Data Validation Audit.Support development of ad-hoc or quality improvement related member and/or provider mailingsAssist with research and correction of issues found in Part D claims adjudication process as neededImpart system expertise to subject matter experts in support of workflow and audit review efforts.Gather and document workflow, detailed business and functional requirements by guiding Delegation Oversight through Clinical workflow processes in alignment with product capabilities.Provide clinical support in data mapping and crosswalk from source systems for auditing tools and scope determinationsProvide clinical guidance in creating specifications for systems to meet business requirements for audits.Provide clinical guidance in documenting and defining the scope of vendor files and systems utilized to parallel overall business strategies and compliance.Maintain compliance within CMS guidelines in all activities performed.Maintain knowledge of policies, plan benefits, and structure.Other duties as assigned.Education and ExperienceAssociates degree or equivalent work experience required, Bachelor’s degree preferred. 5 years of pharmacy experience, preferably in a managed care/health plan environment. Medicare experience preferred.Pharmacy technician certification required.Knowledge of Microsoft Office Suite required (Outlook, Excel, Word)Knowledge of pharmacy claims processing and associated data elements preferred.Demonstrated excellent customer service skills with both internal and external customers required.Broad-based, working knowledge of managed care pharmacy operations required.Ability to work effectively in a fast-paced, dynamic environment required.Strong abilities in verbal and written communication with diverse audiences required.Demonstrated experience with effective time management working with minimal supervision and successful handling of multiple projects simultaneously and prioritize work appropriately.Experience working with all levels of staff and medical practitioners including members, physicians, nurses, and providers.Demonstrated initiative in organizing and prioritizing work to meet deadlines.Certificates, Licenses and RegistrationsWA State, AR, or National Pharmacy Technician registration/license/certification required.','!*!SummaryThe Medicare Clinical Operations Analyst is responsible to support the Medicare Pharmacy Services team in compliance operational processes with Medicare Part D guidelines through development of cross-functional department training and tools within the health plan business, supporting the oversight of delegated services provided by the Pharmacy Benefit Manager (PBM), and supporting clinical quality improvement programs offered by Pharmacy Services division.  Acts as secondary subject matter expertise for pharmacy benefit operations for backup of the Pharmacy Benefit Manager (PBM) role on behalf of the health plan internally and externally to organization. Supports the Delegation Oversight team in clinical data oversight and administration of Medicare delegated vendors.Essential Duties and ResponsibilitiesServe as a liaison between pharmacy department and cross-functional areas for process and policy development compliant with Medicare Part D regulations, to include Direct Member Reimbursement (DMR), Part D Coverage levels, Claims Processing, End Stage Renal Disease, Hospice, etc. that impact retroactive pharmacy claims processing. Development of training materials and education of internal cross-functional staff on pharmacy related Medicare Part D topics. Work with internal staff and the PBM to identify, address and resolve operational issues, and assist with the oversight of corrective actions as needed. Support Medicare Quality Improvement related projects and initiatives as needed. Work cross-functionally with clinical and operational business areas to ensure compliance is achieved through collaborative projects as needed. Supports continual development and maintenance of Medicare Part D Policies, Procedures and departmental objectives to achieve corporate goals. Support development and maintenance of Part D member materials including Formularies, Pharmacy Directories, Explanation of Benefits, Transition Letters, Exclusion Letters, etc. to ensure Medicare compliant documents. Performs utilization and vendor invoice reviews to conduct validation analysis of charges billed to the health plan.Provide escalation support of internal and external calls and emails regarding prior authorization, claims processing, formulary, or coverage inquiries for all health plans nationally.Support successful yearly plan implementation with the PBM, to include completion of the Implementation Questionnaires’, coordination of the Group and Member files and final end-to-end testing of groups, member and benefit configuration prior to the go-live date. Conduct independent recurrent monthly oversight of cross-functional and delegated entity operational tasks such as website posting, customer service support, member reimbursement claims and PBM reports.Conduct oversight of the overall PBM pharmacy claims adjudication process to ensure compliance with plan benefits, cost sharing and Medicare Part D requirements.Support oversight of delegated entity generation of Medicare Part D required reporting and the annual Data Validation Audit.Support development of ad-hoc or quality improvement related member and/or provider mailingsAssist with research and correction of issues found in Part D claims adjudication process as neededImpart system expertise to subject matter experts in support of workflow and audit review efforts.Gather and document workflow, detailed business and functional requirements by guiding Delegation Oversight through Clinical workflow processes in alignment with product capabilities.Provide clinical support in data mapping and crosswalk from source systems for auditing tools and scope determinationsProvide clinical guidance in creating specifications for systems to meet business requirements for audits.Provide clinical guidance in documenting and defining the scope of vendor files and systems utilized to parallel overall business strategies and compliance.Maintain compliance within CMS guidelines in all activities performed.Maintain knowledge of policies, plan benefits, and structure.Other duties as assigned.','We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.','2017-R0140927','QualChoice Health','Clinical Operations Analyst (Pharmacy)

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