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Medical Mutual · 1 month ago

Medicare Pharmacy Coordinator

United States

Full-time

Remote

Mid, Senior Level

4+ years exp

Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio, providing peace of mind to over 1.2 million members. The Medicare Pharmacy Coordinator will administer daily operations in compliance with Medicare benefit programs, focusing on member experience and coordinating various pharmacy-related tasks.

Health CareHealth InsuranceInsuranceLife Insurance

Culture & Values

Responsibilities

Coordinates pharmacy reject review and resolution either directly or forwards/escalates to other departments or PBM. Monitors paid claims for accuracy including for transition supply oversight. Ensures timely communication to members on coverage determination and prescriptions with timeframe restrictions, assesses coverage review accuracy, and triages as needed

Assists in outbound calls to members, providers, and pharmacies to initiate coverage determinations/appeals, prescription refills, and switch members to lower cost therapeutic alternatives based on discussions with providers. Documents all attempts in tracking software

Collaborates with Clinical Intervention Pharmacists on Medicare Stars and other quality initiatives, with a strong focus on member experience. Conducts outreach to Pharmacy Benefit Manager (PBM) for refills, claim reprocessing and to members to provide status of intervention

Tracks and coordinates daily issue/response files with PBM for claim resolution. Outreaches to pharmacy/prescriber as needed

Generates reports from pharmacy system and reviews production metrics

Supports operational oversight overflow and any additional requests. Responds to Part D and Part B benefit questions, updates tracking documents, and ensures effectuation of claims

Builds and maintains knowledge of new or updated CMS regulations, Coverage Gap Discount, Coverage Determinations and Appeals, Grievances, and Medicare marketing material requirements

Assists in internal and external audits and projects of the Medicare Part D (pharmacy) and Part C (medical drug) programs as needed

Performs other duties as assigned

Qualification

CMS guidelinesMedicare Part DPharmacy claims processingCertified Pharmacy TechnicianMicrosoft Office

Required

Associate Degree in Business Administration, Healthcare, or related field or equivalent combination of experience, training, and education

4 – 5 years of experience in a health plan, pharmacy, or PBM operations, which includes exposure to Centers for Medicare & Medicaid Services (CMS) guidelines, preferably Part D

Knowledge of CMS guidelines and Medicare Part D (pharmacy)

Knowledge of pharmacy claims processing through retail or mail pharmacy

Intermediate Microsoft Office skills (Excel, Word, Power Point)

1-2 years of experience as a Medicare Pharmacy Coordinator or equivalent 5-6 years of experience in a health plan, pharmacy, or PBM operations, which includes exposure to Centers for Medicare & Medicaid Services (CMS) guidelines, specifically Part D

Strong knowledge of CMS guidelines and Medicare Part D (pharmacy)

Strong knowledge of pharmacy claims processing through retail or mail pharmacy

Intermediate Microsoft Office skills (Excel, Word, Power Point)

Preferred

Certified Pharmacy Technician (CPhT)

Benefits

Employee bonus program.

401(k) with company match up to 4% and an additional company contribution.

Health Savings Account with a company matching contribution.

Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.

Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.

Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.

After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

Career development programs and classes.

Mentoring and coaching to help you advance in your career.

Tuition reimbursement up to $5,250 per year, the IRS maximum.

Diverse, inclusive and welcoming culture with Business Resource Groups.