Pharmacy Implementation Specialist, Medicare & Duals

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jan 27, 2025
The Medicare Pharmacy Implementation Specialist will be responsible for supporting the Medicare Pharmacy Operations lead with managing the various kinds of reporting that the team will need to review and produce, clinical program analysis, and pharmacy benefit implementation. This role will work closely with the PBM and Senior Clinical Pharmacist(s) to manage yearly and day-to-day clinical and operational tasks of the team and take the lead in PBM oversight for the Medicare and Dual-eligible products as well. This role will also work closely with other departments such as product and marketing to ensure all the Medicare and Dual-eligible pharmacy documents are updated and posted accurately on a monthly, yearly, and ad hoc basis. Overall, this role will include independent pharmacy related research, data analysis, documentation, and program oversight while ensuring compliance with all CMS and state regulations related to applicable Medicare product lines. Principal Duties and Responsibilities: Support the Operational Lead to accomplish key objectives Collaborate with and provide essential data collection and initial analysis to Medicare Clinical Operations Lead or other team members to assist in Medicare and Dual-eligible plan formulary development, implementation, and submissions for multiple formularies and plan types. Comprehensive collection, review, and analysis of data (including but not limited to medical and pharmacy claims, formulary comparisons, pharmacy trend analysis, competitor comparisons, market analysis, utilization data). Support review and QC all the various formulary submission and adjudication coding files, formulary displays, and benefit set up for multiple Medicare and Dual-eligible contracts and PBPs. Support coordination and oversight of PBM related to all PBM and delegated activities (including but not limited to monthly and yearly formulary implementation). Monitor daily claim adjudication for accuracy. Support yearly and ad hoc testing reviews of formulary coding and benefit set up from both a clinical and operational perspective. Maintain various tracking grids for coding and benefit updates made regarding any delegated services to provide a source of truth for various clinical documentation. Provides support for research, analysis, and pulls data to aid Medicare Clinical Pharmacist(s) as well as the larger Clinical Team in developing and monitoring formulary strategies, clinical programs, and all aspects of pharmacy trend mitigation for multiple formularies and plan types. Support periodic quality checks, auditing and oversight of files, coding, and other formulary documents/functions to ensure accuracy of all formulary and benefit coding for multiple formularies and plan types. Maintain policy and procedure documents Assist and collaborate with the PBM and Medicare Clinical Pharmacy Team to provide support for reporting in all aspects: opulling data, reviewing, and performing initial analysis on, then providing summary of the data to pharmacist(s)/team oensuring complete and accurate reporting from the PBM in all areas within the scope of the Medicare Pharmacy Team oCompiling data from various reports to maintain various dashboards and auditing Maintain audit documentation in preparation for potential CMS program formulary administration audit and other types of audits. Assist with formulary updates and submissions for multiple formularies, lines of business and plan types. Aid in development of submission files, and required coding for all related CMS submissions Aid in tracking drug approvals, P&T and Drug Coverage Committee (DCC) review dates, drug launch dates, and financial information to ensure drugs are reviewed and placed on the formulary within CMS required time frames. Support collaboration with the marketing and communications team in the development and preparation of educational materials (clinical and operational in nature) for internal and external audiences. Works alongside the marketing and web teams to ensure pharmacy web links containing CMS required documents are accurate and posted in accordance with CMS expectations. Assist in researching and resolving member issues. Provide operational-related subject matter expert (SME) support for various Pharmacists, Care Managers, and other applicable teams. Participate in and support Senior Clinical Pharmacist(s) and team in all auditing activities. including researching audit universes, claims history, and formulary/benefit coding to determine possible issues and resolution. Assist in monitoring and tracking applicable regulatory updates, changes, and memos (state and federal level). As an integral member of a larger clinical team, may be asked to provide support and/or collaborate with Clinical Pharmacist(s) and larger clinical team as a whole on other lines of business. Hold self and others accountable to meet commitments. Ensure diversity, equity, and inclusion are integrated as a guiding principle. Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization. Other duties as assigned with or without accommodation. Qualifications: * Bachelor's degree in related field required or the equivalent combination of training and experience, plus two years of Medicare and or Dual-eligible plan pharmacy related experience. * Minimum two years' experience in Medicare and/or Dual-eligible managed care pharmacy * Pharmacy Technician Certification (PTCB) preferred. * Experience with benefit and drug coding logic for adjudication. * Experience with CMS audits. Skills/Abilities/Competencies: * Proficiency in Microsoft Word and Excel. * Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value. * Bring fresh ideas forward by listening to and working with employees and the people we serve. * Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner. * Strong, demonstrated track record of an ability to execute on time, on budget, and on scope. * Strong aptitude for technology-based solutions. * Ability to inject energy, when and where it's needed. * Current in healthcare trends. * Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be." * Ability to develop, introduce, defend, and gain support for a new ideas and approaches. * Excellent leadership skills and leadership track record. * Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. Strong verbal, active listening, and written communication skills required. * Ability to view the long-range trends and cycles of the business and industry and see the "big picture." * Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions. * Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy. * Excellent interpersonal skills, including the ability to influence others at all levels of an organization. * Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. * Unquestionable integrity. Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.