Title: Pharmacy Operations Specialist-Paramount

Location: United States

Job Description:

Note: this position has the option to work hybrid or remote. Eastern or Central Time Zones preferred.

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.6 million Ohioans through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Serves as a liaison between Sales, Pharmacy Operations, Benefit Services, Communications, and the Pharmacy Benefit Manager (PBM) to bridge the gap between front-end group benefits/requirements and back-end operations/claim processing. Optimizes the implementation of new prescription drug groups and programs.

Responsibilities

Performs quality checks of claims processing following audit workplan, and tests claims for selected benefits, programs, or groups to ensure the PBM system is set correctly to process claims according to health care reform, the Company, group expectations, and according to contractual terms with group and PBM.
Coordinates pharmacy implementation activities with various internal departments for new clinical, operational, or contractual programs/requirements such as marketing materials, sales training, benefit configuration, benefit claim testing, contract auditing, provider or member communications, certification changes, etc. Ensures program updates are successfully completed for existing groups upon renewal.
Coordinates with sales, pharmacy benefits, and PBM vendor to onboard incoming client groups for plan design, plan ID creation for included or excluded drugs, claim, and benefit testing, and ensure accuracy and timeliness of file transfers and member communications. Advises groups on impact of removing a drug or drug class from coverage. Attends new group implementation meetings with sales to define what is needed for the benefits and unique programs. Interprets client directions for coverage into benefit set-up documents and ensure that drugs are correctly processed.
Creates and tests Plan IDs to ensure correct inclusion and exclusion of drugs from group&#39;s benefit coverage. Checks National Drug Code (NDC) directory and drug names to determine if drugs are in correct drug classes and intent of client is aligned with PBM. Applies pharmacy knowledge to determine if drugs are OTC, anabolic steroid, DME, contraceptive, etc.
May assist with web postings and updates (e.g., formulary postings) and member service inquiries.
May assist department with regulatory related functions such as NCQA accreditation activities, interpretation of new guidance, updates to policies and procedures.
Performs other duties as assigned.

Qualifications

Education and Experience

Bachelor&#39;s degree in pharmacy, healthcare, or business administration, or related field preferred, but will consider collective experience, education, and training.
5 years of relevant experience in a PBM or a health plan (i.e. benefit services/coding, communications, customer service, account management) or a relevant healthcare setting.

Professional Certifications

Certified Pharmacy Technician (CPhT) or related education/training required.
Certification in process improvement, project management, or similar preferred.

Technical Skills and Knowledge

In depth knowledge of claim processing from retail pharmacy aspect including drug knowledge of classes and indications, appropriate doses and frequencies, pharmacy calculations, and Ohio and Federal Drug Laws.
Strong knowledge of pharmacy and medical drug benefits, PBM claims processing and benefit set-up requirements.
Knowledge of PPACA rules for pharmacy benefits and Ohio state laws regarding health plan business.
Intermediate to advanced Microsoft Office (especially Excel) skills. Proficiency with database reporting.
Ability to develop and manage process flows.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
Discounts at many places in and around town, just for being a Medical Mutual team member.
The opportunity to earn cash rewards for shopping with our customers.
Business casual attire, including jeans.

Excellent Benefits and Compensation:

Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Excellent medical, dental, vision, life and disability insurance - insurance is what we do best, and we make affordable coverage for our team a priority.
Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

Career development programs and classes.
Mentoring and coaching to help you advance in your career.
Tuition reimbursement up to $5,250 per year, the IRS maximum.
Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

Medical Mutual

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