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    Pharmacy Benefits Strategist

    Pacificsource Health Plans
    2+ years
    Not Disclosed
    Salem
    10 Dec. 6, 2024
    Job Description
    Job Type: Full Time Education: B.Sc./ M.Sc./ M.Pharm/ B.Pharm/ Life Sciences Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, CPC Certified, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

    Make an Impact and Help People - Join PacificSource!

    Are you passionate about making a difference in people's lives by helping them access quality, affordable healthcare? PacificSource is looking for dynamic individuals to join our team and contribute to the success of our pharmacy benefit programs.

    Why PacificSource? At PacificSource, we value diversity and inclusivity, and we are committed to creating a workplace where each individual is appreciated, respected, and encouraged to thrive. We are an equal opportunity employer, offering all qualified applicants equal consideration without regard to race, religion, gender identity, or other protected statuses.

    Position Overview: This role focuses on supporting all aspects of the pharmacy benefit, working closely with Pharmacy leadership on designing, implementing, and coordinating pharmacy program initiatives. You will play a key role in Pharmacy Benefit Management (PBM) operations, utilization management platform operations, pharmacy/data analytics, and business analysis and process improvement.

    Essential Responsibilities:

    • Oversee and ensure the accurate setup of pharmacy benefit designs, formulary coding, network coding, drug pricing, PBM configuration testing, and claims analysis.
    • Collaborate with Sales, Product Development, and Pharmacy teams to optimize pharmacy benefit designs and initiatives.
    • Support the Sales team by generating and analyzing claims data, formulary comparisons, and projections for both new and existing groups.
    • Coordinate with vendors, consultants, and clients to ensure the efficient implementation of coding, including monitoring PBM operations, data interfaces, and communications.
    • Manage ongoing drug and claim configuration setup and testing to ensure accuracy of point-of-service adjudication.
    • Provide claims research, analysis, and support during audits.
    • Track and record drug launches to facilitate coverage and formulary decisions.
    • Create and maintain departmental performance dashboards.
    • Build reports using internal software and extract data from the data warehouse for pharmacy reporting and analysis.
    • Analyze medical and pharmacy claims to identify cost-saving opportunities and process improvements.
    • Present complex data and findings to internal and external teams in a clear and understandable manner.
    • Participate in special projects and committees as needed.

    Success Profile:

    • Minimum of 5 years of healthcare experience, ideally within managed care or pharmacy.
    • Preference for experience with Medicare Star ratings, Medicaid quality initiatives, and NCQA standards.
    • Strong skills in data analysis, with proficiency in software such as RxClaim, SQL, SAS, Excel, or Tableau.
    • Bachelor's degree in public health, healthcare-related field, mathematics, statistics, or data science (or equivalent experience).
    • Expertise in coding, analytics, and claims analysis is required.
    • SQL experience is preferred.

    Required Competencies:

    • Adaptability, Communication (written/verbal), Problem-Solving, Teamwork, and Organizational skills.
    • Ability to work independently, meet deadlines, and manage complex problems effectively.

    Our Values: At PacificSource, we are guided by our core values:

    • Doing the right thing.
    • Working as one team.
    • Providing excellent customer service.
    • Open communication for growth.
    • Advancing social justice, equity, and inclusion.
    • Encouraging creativity, innovation, and excellence.

    Environment: Work in a general office setting with ergonomic equipment. Occasional travel (approximately 10% of the time) may be required.

    Physical Requirements: Ability to sit/stand for long periods, perform repetitive motions (typing, sorting, filing), and occasionally lift files or materials. Must have the ability to read, comprehend, and communicate effectively in English.

    Take the Next Step: Ready to help PacificSource make a positive impact on healthcare? Join our team and contribute to our mission of providing access to affordable and quality care. Apply today!

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