The Part D Pharmacist is responsible for assisting with the development of the Medicare Part D audit program and ensuring that audits are conducted with adherence to clinical compliance, CMS guidelines, and accuracy of the assigned business area, for our client. This will include assisting in the development of audit tools and recommending changes in processing procedures. They will have the ability, and be expected to drive change, and positively impact the accuracy and efficiency of operations by recommending actions that address error trends and root-causes of errors found during quality audits.
They will utilize expert drug knowledge to perform a clinical review of Pharmacy Part D Coverage Determinations, Appeals, and Grievances for our client. The goal is to improve both clinical appropriateness and cost effectiveness of drug therapy. The Part D Pharmacist will use evidence based medicine, utilization management criteria, and clinical guidelines to ensure appropriate utilization management is applied to appeal requests.
Active Pharmacist License in home state, with no restrictions
Ability to obtain additional license elsewhere, if needed
Previous experience with clinical review of Medicare Part D coverage determinations, appeals and grievance and claims audits, preferably for a health plan or a pharmacy organization
Strong time management, communication skills, and organizational skills required
Strong technical skills, to navigate multiple systems and tools at once, with ease Responsibilities:
Review Medicare Part D appeal and coverage determination requests by applying utilization management criteria for an internal medical review
Review Part D appeal, coverage determination requests to ensure appropriate patient safety such as drug-drug interactions, drug-disease interactions, drug-age precautions, therapeutic duplications, and overutilization
Maintaining excellent understanding of evidence based medicine clinical guidelines
Identifies billing, benefit, and coding errors and track these errors to resolution
Ensure organizational compliance with Federal and State governmental (e.g., CMS, Medicaid, etc.), departmental, and company guidelines
Perform specific quality reviews for specific requests as needed, ad hoc
Perform weekly, monthly and/or quarterly quality reviews as directed to support each function within the end to end process, at each program level
Provide timely and constructive feedback on audits to drive quality improvement
Provide effective communication to engage and develop cross functional staff in a virtual environment
Delivers communications positively and is supportive of organizational goals and objectives
Collaborates with matrix partners in Compliance, Claims, National Quality, and Networks to ensure objectives and standards are met, policies and procedures are followed, gaps identified and closed, communications are clear Preferred Qualifications:
Previous successful work at home experience
Previous leadership or people management experience preferred
About the Company
BroadPath provides specialized business, compliance, and technology services to healthcare payers and providers in commercial and government sectors.
We focus solely on healthcare, so our team understands our clients' issues in a way few others can. And since we work with the country's top healthcare organizations, we have unique insight into the industry's best practices and of the dynamics and regulations affecting operations and outcomes.
Employment Type: Permanent
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