Reports To: Mgr., Pharm Compliance Audit, RX-State & Benefit RelationsDept.: Pharmacy Location: George Road, Tampa, FLThis position is located in Tampa, FL. Shift: Monday - Friday, 10:00am to 7:00pm.
Coordinates and controls the workflow occurring in and out of the department. Serves as a liaison between WellCare and its Pharmacy Benefit Manager (PBM) for all aspects of pharmacy claims processing issues. Coordinates and supports audit related activities, specifically surrounding information gathering and analytical evaluation of preliminary audit results. Partners closely and coordinates with other pharmacy and functional departments on a frequent basis to ensure synergies and cross-departmental effectiveness.
Reviews and tracks all aspects of pharmacy claims processing for completeness and coding accuracy.
Manually updates PBM eligibility to sync with WellCare enrollment systems on a daily basis where updates are not made available through batch loading in the PBM system.
Responsible for making updates in the PBM system as part of Medicare Part D PDE reconciliation.
Maintains the integrity of the data loaded in to the PBM.
Performs ongoing claims testing to ensure accuracy of adjudication at Point of Service.
Researches, troubleshoots and resolves claims issues with internal and external partners.
Escalates issues to the PBM account team, where appropriate, and seeks follow-ups, as necessary until resolution.
Serves as primary point of contact to the escalated Pharmacy call center support staff on PBM issues.
First tier point of contact for information gathering in audits relating to pharmacy claims processing, including audits by state and federal agencies.
Provides claims research, analysis, and support during audits.
Tracks requests coming into the department and evaluates trends; involving others as necessary.
Oversees the daily, weekly, and monthly receipt of Third Party Vendor files.
Supports leadership and the department on a wide array of PBM related initiatives, tasks and projects related to all aspects of the plans' pharmacy benefit for all lines of business.
Follows all state and federal regulations and contractual requirements, including record retention requirements.
Performs other duties as assigned.
Additional Responsibilities: Candidate Education:
Required An Associate's Degree in a related field
Required or equivalent work experience
Preferred A Bachelor's Degree in a related field
Required 2 years of experience in pharmacy or managed care environments
Preferred Other familiarity with the pharmacy software utilized by WellCare and the PBM is a plus.
Intermediate Ability to communicate and make recommendations to upper management
Intermediate Ability to effectively present information and respond to questions from peers and management
Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Intermediate Ability to represent the company with external constituents
Advanced Ability to work in a fast paced environment with changing priorities
Intermediate Demonstrated analytical skills
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated organizational skills
Intermediate Demonstrated problem solving skills
Intermediate Knowledge of healthcare delivery
Licenses and Certifications: A license in one of the following is required:
Preferred Certified Pharmacy Technician (CPhT)
Required Intermediate Microsoft Excel
Required Intermediate Microsoft PowerPoint
Required Intermediate Microsoft Outlook
Required Intermediate Healthcare Management Systems (Generic)
About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.