Health First Pharmacy Operations Manager - HFHP, Full-Time in Rockledge, Florida
To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship by: Being responsible for overseeing all operational business processes of the pharmacy department, including formulary development, drug utilization and cost analysis, and the coverage determination and exception processes. The pharmacy manager ensures that the Pharmaceutical Services Department provides optimal services; meets all legal, accreditation, and certification requirements, and complies with all applicable policies, procedures, codes, and standards of Health First, Inc.
PRIMARY ACCOUNTABILITIES: * Manages operational processes for coverage determination and exception request and meets all regulatory requirements by governing agencies. * Conduct and participate in group meetings. * Assists in and maintaining a medical staff-approved formulary. * Establishes and follows Policies and Procedures in line with State and Federal regulations, including CMS to ensure compliance. * Continuous involvement in meeting and exceeding measurable quality standards as established by NCQA, CMS, HEDIS, etc. * Communicate with providers and members regarding formulary changes ensuring compliance with governing agencies. * Ensures applicable CE records and licensure are maintained in department files. * Insure proper use of treatment criteria, protocols and edits for Pharmacy benefit as developed by medical staff * Ensures accurate processing and timeliness of claims and coverage determinations by developing and monitoring audit tools and metrics around pharmacy processes. * Manages audit team in the activities of mapping, observing, interviewing and analysis determined by the scope of the audit. Facilitate and manage meetings to review, interpret and analyze audit data throughout the audit.
QUALIFICATIONS REQUIRED: * Bachelor Degree preferred * 5 years’ experience in the pharmacy field with managed care or PBM experience. * Experience in Part D claims processing preferred. * Understands all the functions of a pharmacy benefit management company. * Experienced in configuring pharmacy benefit software and managing functions performed by a full-service PBM company. * Exceptional interpersonal relationship skills. * Proficient in word processing, graphics and spreadsheet manipulation and basic understanding of the Internet. * Demonstrates excellent written and verbal communication skills conforming to all rules of punctuation, grammar, diction and professional style. * Presents professional image to the public. * Experienced in initiating, developing and monitoring policies, internal control procedures and operating standards. * Experienced in monitoring metrics and trends around pharmacy processes. * Ability to conduct training and make oral presentations to large and small groups. * Experienced in initiating, developing and monitoring policies, internal control procedures and operating standards. PHYSICAL DEMANDS: * Repetitive use of hands and fingers. Good hand and wrist dexterity to enable typing and/or computer work for 8-10 hours/day. * Good hearing to understand phone instructions/orders, customers and those in which the position depends. * Ability to work in noisy distracting atmosphere, to handle frequent interruptions, to adapt to changes in workload and work schedule. * Handle large volumes of work for long periods of time. * Walk, bend, stoop, twist, sit, and stand for long periods of time, 8-10 hours a day. * May require lifting and carrying light loads (Up to 40 lbs.)
Organization: *Health First, Incorporated
Title: Pharmacy Operations Manager - HFHP, Full-Time
Location: Florida - Brevard County-Rockledge
Requisition ID: 035864