The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.
Work Culture:
GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work – Together.
GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).
GCHP’s focuses on 5 Core Values in the workplace:
• Integrity
• Accountability
• Collaboration
• Trust
• Respect
Disclaimers:
• Flexible work schedule is based on job duties, department, organization, or business need.
• Gold Coast Health Plan will not sponsor applicants for work visas.
POSITION SUMMARY
The Medicare PBM Operations Manager reports directly to the GCHP Director of Pharmacy Services and is responsible for overseeing the PBM operations and Part D initiatives in alignment with overall D-SNP strategy as set by the D-SNP leadership. The position will regularly interface with PBM vendor, consultants, pharmacies, provider offices, and members. The Medicare PBM Operations Manager will lead initiatives related to pharmacy benefits and managing associated personnel, programs, and services. These initiatives and programs include execution of pharmacy benefits implementation, product development, utilization management, quality improvement, regulatory compliance, and business development projects. This position will do so by supporting the Director of Pharmacy Services and D-SNP leadership in coordinating activities among key vendors and internal leadership. Additionally, this position will be responsible for providing direction and leadership to pharmacy technicians as needed. Finally, this position will provide project management support, human resource management support, and community service support in associated areas of responsibility.
The Medicare PBM Operations Manager will serve as a key subject matter expert in both pharmacy benefit management operations and retail pharmacy operations. This position will take on advanced responsibilities in regulatory compliance, staff oversight, and training related to all aspects of Part D pharmacy benefits. This position will also support and/or drive development of plan products, benefit designs, and services. The breadth of responsibilities will vary widely and require a thorough understanding of system processes and financial implications of decisions related to pharmacy benefits.
Amount of Travel Required: 10%
Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.
ESSENTIAL FUNCTIONS
Job Function & Responsibilities
• Responsible for claims operations issue management support and audit functions. Determines specific business application software requirements to address the most highly complex and varied business needs.
• Analyzes and designs solutions to address varied and complex business needs.
• Translating complex and varied business needs into application software requirements. These needs typically involve a significant expenditure or cost savings and impact a wide range of functions. Provides expertise on the analysis of business needs to determine optimal means of meeting those needs.
• Regularly interface with PBM. As well as with consultants, pharmacies, provider offices, and members as required.
• Lead initiatives related to pharmacy benefits and managing and overseeing PBM, associated programs, and services. Ensuring that the PBM is compliant with all regulatory requirements.
• These initiatives and programs include execution of pharmacy benefits implementation, product development, utilization management, quality improvement, regulatory compliance, and business development projects.
• Support the Director of Pharmacy Services, D-SNP leadership, and Health Services leadership in coordinating activities with our PBM and other leadership.
• Provide project management support, human resource management support, in associated areas of responsibility.
• Serve as a key subject matter expert in both pharmacy benefit management operations and retail pharmacy operations.
• Take on advanced responsibilities in regulatory compliance, and training related to all aspects of pharmacy benefits for Part D Medicare.
• Support and/or drive development of plan products, benefit designs, and services for Part D Medicare with direction from the Director of Pharmacy Services and D-SNP leadership.
MINIMUM QUALIFICATIONS
Required Education and Experience:
• Bachelor’s Degree in Healthcare Administration, Business Administration, or in a related field
• 5 years of experience in the managed care pharmacy analytics or pharmacy benefit management (PBM) industries
• Experience in retail pharmacy operations, as a Certified Pharmacy Technician
• Experience in project management
• Specialized subject matter expertise in Medicare Advantage Prescription Drug Plan and Medicaid
Preferred Education and Experience:
• Pharmacy Claims Experience (Adjudication experience)
• Prior experience with CMS and NCQA audits
• Broad and detailed knowledge of Medicare Part D operations and best practices
KNOWLEDGE, SKILLS & ABILITIES
Preferred Qualifications:
• Ability to quickly learn multiple software tools
• Working knowledge of Customer Relation Management (CRM) tools
• Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes.
• Ability to assume responsibility and exercise good judgment with making decisions within the scope of the position.
Technology & Software Skills: Advanced computer skills in MS Office products.
Certifications & Licenses:
• A valid and current Driver's License, Auto Insurance, and professional licensure(s)
• Current Pharmacy Technician License (if applicable)
Competency Statements
• Management Skills - Ability to organize and direct oneself and effectively supervise others.
• Business Acumen - Ability to grasp and understand business concepts and issues.
• Decision Making - Ability to make critical decisions while following company procedures.
• Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
• Interpersonal - Ability to get along well with a variety of personalities and individuals.
• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
• Relationship Building - Ability to effectively build relationships with customers and co-workers.
• Presentation Skills - Ability to effectively present information publicly.
• Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.
• Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
• Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.
• Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
• Judgment - The ability to formulate a sound decision using the available information.
• Communication, Oral - Ability to communicate effectively with others using the spoken word.
• Communication, Written - Ability to communicate in writing clearly and concisely.
• Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.
