Pharmacy Benefits Specialist Commercial - Full Time-SHP- Telecommuter
- Health Plan
Shift Start Time:9 AM
Shift End Time:6 PM
Additional Shift Information:
Weekend Requirements:Not Specified
Hourly Pay Range (Minimum - Midpoint - Maximum):$71.822 - $92.673 - $113.525
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will Do
Under the direction of the Manager, Pharmacy Benefits, the Pharmacy Benefits Specialist-Commercial position provides leadership and oversight for the Commercial pharmacy program, with a particular focus on Commercial/PPO/Exchange products. The Pharmacy Benefits Specialist will assist with the development, management, and oversight and monitoring of the Sharp Health Plan benefits, clinical programs, formulary, regulatory requirements, prior authorizations, and medical policies to provide the best value to members. This position coordinates pharmacy benefits for members and physicians with direct and frequent contact with Sharp Health Plan's pharmacy benefits management vendor.
- Doctor of Pharmacy (PharmD) : Pharmacy degree from an accredited college or university.
- 3 Years experience in managed care.
- 2 Years experience in clinical and regulatory requirements
- 1 Year Health Plan experience.
- California Pharmacist License - CA State Board of Pharmacy -REQUIRED
- 2 Years experience in a managerial or leadership role.
- Pharmacy Benefit Management (PBM) experience or working with a PBM.
- Pharmacy Financial Attributes
Identifies, implements, and monitors cost reduction measures or revenue enhancing opportunities.
- Customer Service
Provides prompt, accurate and excellent service to internal and external customers.
Demonstrates positive and professional communication with members, physicians, staff and vendors, as applicable.
Participates in special projects as assigned. these may include, but are not limited to: work groups, proposals, audits and back-up for other departments.
Addresses appeals and grievances related to pharmaceutical care.
- Line of Business Oversight
Ensures pharmacy benefit management vendor compliance with plan standards, guidelines, and regulatory requirements, including State of California, DMHC, and Federal rules and regulations.
Performs monitoring and oversight activities including but not limited to clinical reviews of prior authorizations, rejected and paid claims and audit activities.
Reviews contractual performance of vendors against work performed to ensure compliance with contract and regulatory requirements.
Investigates and responds to regulatory inquiries.
Gathers accurate data relating to audit requests and ensures data is reported in a repeatable and reproducible format.
Prepares documents for regulatory filings, such as audit material, EOCs, Policies and Procedures, EHB documents and required reports.
Prepares documents for internal and external Committees.
Collaborates with team on development and monitoring of fraud, waste, and abuse initiatives for pharmacy. This may include medication safety initiatives, adverse drug reaction reporting activities and adherence monitoring.
Ensures timely submission of required regulatory filings (e.g. formulary, Essential Health Benefit formulary compliance, Mental Health Parity analysis, etc.).
- Line of Business Supervision
Assists Manager, Pharmacy Benefits in managing departmental activities, monitors productivity and work flow, and ensures operational efficiency and quality of services.
Maintains departmental policies and procedures; ensures appropriate review and revision.
Ensures compliance with applicable contract terms, legal/regulatory requirements and accreditation standards.
Identifies and resolves operational problems and inefficiencies to ensure continued high-quality service and achieve required results.
- Financial Accountability
Supports organizational cost containment.
Actively sets priorities and adjusts to unscheduled situations.
Accepts responsibility for own actions and outcomes.
Effectively institutes changes, supporting department and organizational goals.
Identifies departmental or organizational problems, develops and/or contributes to a plan to resolve problems.
Implements and/or assists with plans to achieve resolution.
- Human Resource Management
In conjunction with Manager, Pharmacy Benefits, interviews staff and prospective staff.
Provides supervision, training, and continuing education for staff.
Assesses staff skill levels and training needs. Ensures staff receives information and training needed to maintain compliance and effective performance.
Ensures consistent application of human resources policies and Health Plan protocols.
- Other Duties
Keeps current in knowledge of State and Federal regulatory requirements, clinical standards, recent innovations in pharmaceutical care, and availability of alternative resources. Accomplishes this by ongoing involvement in formal continuing education courses, review of professional publications, and other relevant sources of information.
Performs other duties as assigned to contribute to the overall success of the organization.
Knowledge, Skills, and Abilities
- Must have thorough working knowledge of pharmacy operations, processes and policies appropriate to pharmacy benefit management.
- The ability to analyze and interpret data and prepare concise, accurate reports.
- The ability to initiate studies, gather statistical data and trend outcomes.
- Must have excellent written and verbal communication skills.
- Strong organizational, analytical and problem-solving skills.
- Must be proficient with Microsoft Office.
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class
Doctor of Pharmacy (PharmD); California Pharmacist License - CA State Board of Pharmacy
Want to know when new jobs are posted? Sign up for job alerts.
Set your parameters to automatically receive alerts when we post new jobs that fit your skills, interests and experience.
"After nearly 10 years of working here, it's still one of the hardest jobs I've ever loved. If you find a niche here, you'll be working with some of the smartest in the industry. This is where they'll respect you for thinking outside the box and kindness matters. They expect consistency and hard work, but pay you well to do it."
We are Sharp
Stay connected and join the career interest community
Want to stay informed about career opportunities and life at Sharp? Join our career interest community and receive information that matters to you.Join the community