Pharmacy Audits And Monitoring Specialist
MCS Puerto Rico, San Juan, San Juan, United States
General Description
Responsible for monitoring the execution of the Pharmacy Benefits Managers (PBM) Lines of Business (LOB) and/or applicable processes. Monitors all Pharmacy processes related to performance guarantees and contractual agreements to ensure compliance with the Center for Medicare and Medicaid Services (CMS) regulations. Ensures an action plan to guarantee the PBMs comply with reporting requirements, formulary utilization management, transition processes, coverage determinations, and new regulations. These responsibilities are tied to all the company's LOBs and its subsidiaries' activities.
Regular, Non-Exempt
Essential Functions
Evaluate the Office of Inspector General (OIG) and Preclusion pharmacy claims rejections to guarantee the system does not allow payments from excluded doctors/pharmacies as established by CMS.
Evaluate the OIG and Preclusion pharmacy claims payments to guarantee the system does allow payments from reinstated doctors/pharmacies as established by CMS.
Monitors Medicare Drug Management Program (DMP) to ensure compliance with CMS requirements.
Oversee beneficiary and provider transition letters to ensure consistency with CMS-approved marketing materials; verify accuracy (drug message, drug name, dosage, demographics) and delivery within CMS-required timelines.
Analyzes and identifies inappropriate transition rejections of new and existing beneficiaries; ensures access to medications for any inappropriate rejection.
Identify patterns and tendencies and implement action plans for any monitored processes in non‑compliance with CMS regulations.
Monitors the company's LOBs performance to guarantee accuracy, timeliness, and compliance with contractual agreements, and utilization management for formulary rejections approved by CMS.
Monitors End-Stage Renal Disease (ESRD) and Hospice beneficiaries' Part D retrospective payments.
Monitors inappropriate, inactive, or invalid medication rejections by the DEA (Drug Enforcement Administration) to assist pharmacies in processing‑controlled medications so patients obtain these medications.
Accurately develop and monitor pharmacy directories for company LOBs to ensure they are accurate and available on the plan sponsor webpage.
Monitors formulary-rejected claims to ensure alignment with CMS-approved formularies.
Monitor the PBM call center metrics, maintaining tracking logs, request action plans as applicable, and track completion.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
Minimum Qualifications
Education and Experience: Bachelor's Degree in Business Administration, Health Administration, Public Health or related fields. At least two (2) years of experience in pharmacy operations, audit, and compliance, including monitoring PBM performance, formulary management, adherence to CMS regulations, pharmacy directory management, or beneficiary/provider communications within a regulated healthcare environment.
OR
Education and Experience: Associate’s Degree in Pharmacy Technician. At least four (4) years of experience in pharmacy operations, audit, and compliance, including monitoring PBM performance, formulary management, adherence to CMS regulations, pharmacy directory management, or beneficiary/provider communications within a regulated healthcare environment. For an Associate’s Degree, a valid License and Registration as a Pharmacy Technician is required.
Other: Intermediate proficiency in Microsoft Word and PowerPoint. Advanced Excel knowledge, including PivotTables, VLOOKUP, formulas, tables, filters, and graphs. Preferred knowledge of pharmacy claims processing platforms and clinical programs. Understanding of clinical criteria, pharmacy practice regulations, managed care, and Medicare Advantage requirements.
Languages
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)
We are an Equal Employment Opportunity Employer and take affirmative action to recruit protected veterans and individuals with disabilities.
#J-18808-Ljbffr
Responsible for monitoring the execution of the Pharmacy Benefits Managers (PBM) Lines of Business (LOB) and/or applicable processes. Monitors all Pharmacy processes related to performance guarantees and contractual agreements to ensure compliance with the Center for Medicare and Medicaid Services (CMS) regulations. Ensures an action plan to guarantee the PBMs comply with reporting requirements, formulary utilization management, transition processes, coverage determinations, and new regulations. These responsibilities are tied to all the company's LOBs and its subsidiaries' activities.
Regular, Non-Exempt
Essential Functions
Evaluate the Office of Inspector General (OIG) and Preclusion pharmacy claims rejections to guarantee the system does not allow payments from excluded doctors/pharmacies as established by CMS.
Evaluate the OIG and Preclusion pharmacy claims payments to guarantee the system does allow payments from reinstated doctors/pharmacies as established by CMS.
Monitors Medicare Drug Management Program (DMP) to ensure compliance with CMS requirements.
Oversee beneficiary and provider transition letters to ensure consistency with CMS-approved marketing materials; verify accuracy (drug message, drug name, dosage, demographics) and delivery within CMS-required timelines.
Analyzes and identifies inappropriate transition rejections of new and existing beneficiaries; ensures access to medications for any inappropriate rejection.
Identify patterns and tendencies and implement action plans for any monitored processes in non‑compliance with CMS regulations.
Monitors the company's LOBs performance to guarantee accuracy, timeliness, and compliance with contractual agreements, and utilization management for formulary rejections approved by CMS.
Monitors End-Stage Renal Disease (ESRD) and Hospice beneficiaries' Part D retrospective payments.
Monitors inappropriate, inactive, or invalid medication rejections by the DEA (Drug Enforcement Administration) to assist pharmacies in processing‑controlled medications so patients obtain these medications.
Accurately develop and monitor pharmacy directories for company LOBs to ensure they are accurate and available on the plan sponsor webpage.
Monitors formulary-rejected claims to ensure alignment with CMS-approved formularies.
Monitor the PBM call center metrics, maintaining tracking logs, request action plans as applicable, and track completion.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
Minimum Qualifications
Education and Experience: Bachelor's Degree in Business Administration, Health Administration, Public Health or related fields. At least two (2) years of experience in pharmacy operations, audit, and compliance, including monitoring PBM performance, formulary management, adherence to CMS regulations, pharmacy directory management, or beneficiary/provider communications within a regulated healthcare environment.
OR
Education and Experience: Associate’s Degree in Pharmacy Technician. At least four (4) years of experience in pharmacy operations, audit, and compliance, including monitoring PBM performance, formulary management, adherence to CMS regulations, pharmacy directory management, or beneficiary/provider communications within a regulated healthcare environment. For an Associate’s Degree, a valid License and Registration as a Pharmacy Technician is required.
Other: Intermediate proficiency in Microsoft Word and PowerPoint. Advanced Excel knowledge, including PivotTables, VLOOKUP, formulas, tables, filters, and graphs. Preferred knowledge of pharmacy claims processing platforms and clinical programs. Understanding of clinical criteria, pharmacy practice regulations, managed care, and Medicare Advantage requirements.
Languages
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)
We are an Equal Employment Opportunity Employer and take affirmative action to recruit protected veterans and individuals with disabilities.
#J-18808-Ljbffr