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Pharmacy Benefits Specialist Commercial - Full Time-SHP- Telecommuter

Job ID JR143670 Date Posted 11/02/2023
San Diego, California
  • Health Plan
  • Day
  • Regular
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Shift Start Time:

9 AM

Shift End Time:

6 PM

Additional Shift Information:

Weekend Requirements:

Not Specified

On-Call Required:


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.

Required Qualifications
  • 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

Preferred Qualifications
  • 2 Years experience in a managerial or leadership role.
  • Pharmacy Benefit Management (PBM) experience or working with a PBM.

Essential Functions
  • 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
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