Overview

Under the general supervision of the Director, the Sr. Pharmacy Operations Program Coordinator provides a full range of advanced level complex support services. The primary responsibilities of the program coordinator includes providing pharmacy service to Medicaid providers, review pharmacy claims for accurate billing, screen for fraud, waste and abuse, handle in-coming calls from pharmacy providers, conducting outreach and follow up calls to members and or pharmacies to ensure access to medications, updating client records in proprietary database and reporting program activities and results.

Responsibilities

Serve as a Pharmacy Program contact for other MassHealth units as it relates to all operational activities for the Pharmacy Program.Assist with operational activities within Pharmacy Program, to include the Pharmacy On-line Processing System Vendor and Drug Use Review (DUR), including identifying and completing tasks.Review pharmacy claims for accurate billing, screen for fraud, waste and abuse.Handle in-coming calls from pharmacy providers, conduct outreach and follow up calls to members and or pharmacies to ensure access to medications.Update client records in proprietary database and report program activities and results.Ensure current pharmacy claims are adjudicating properly.Ensure proper billing procedures are being practiced.Identify billing inconsistencies that would be appropriate to audit.Act as a contact with Pharmacy Providers to communicate operational concerns and problem resolution.Assist in the enrollment and credentialing of all Pharmacy Providers.Support efforts for Pharmacy Program Integrity as it relates to Pharmacy Claims.Monitor provider compliance with Pharmacy regulations and policies.Provide technical assistance and advice to staff concerning assigned programs in order to exchange information, resolve problems and ensure compliance with established policies, procedures and standards.Lead small projects or subcomponents of larger, more complex projects in collaboration with the Director or designee.Assist in the coordination of programs to ensure effective implementation of servicesEnsure that program-related activities are timely, successful, and if applicable, meet customer expectationsPerform preliminary data collection and analysis for review with senior staff.Extracts preliminary results from data analysis and presents to senior staff and project teams.Develop and maintain an effective relationship with team members, senior leadership and other project stakeholders.Update the Director or designee on issues or challenges related to program administration in a timely manner.Make recommendations for changes in procedures and guidelines and formulate strategies for accomplishing program objectives.Prepare multi-media presentations and reports utilizing a variety of software applications.May participate in oral and written reporting and presentations of project findings.Review pertinent correspondence, communications and other background materials on a daily basis to remain current on project and operation details.Contributes to high-performing teams by looking for opportunities to contribute to individual and broader team goals, remains flexible for both schedule and business needs while easily adapting to changes at work to enables supportive, collaborative, and challenging work environment.Independently identify and report data patterns and abnormalities.Provide analysis of key metrics and data trends.Demonstrate exceptional analytic and problem-solving skills.Maintain the confidentiality of all business documents and correspondence per UMass Chan/CWM policies and HIPAA regulationsPerform other related program duties as assigned.

Qualifications

REQUIRED EDUCATIONBachelor’s degree or equivalentREQUIRED WORK EXPERIENCE3 years of relevant pharmacy experience Demonstrated project coordination skills, demonstrated experience in setting priorities, delegation of duties, and independent decision-makingAbility to work in a team and meet performance deadlines in a dynamic environment.Possess the organizational, verbal, written and interpersonal skills necessary to interact effectively with all levels of personnelProficient in Microsoft Office productsDemonstrated ability to work appropriately with confidential information. PREFERRED EDUCATIONBachelor’s Degree or equivalent.PREFERRED WORK EXPERIENCEExperience in pharmacy claims and billing.

Additional Information

Pharmacy Technicians encouraged to apply

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