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J194115

Manager Pharmacy Government Operations

Highmark Inc.

  • Company Highmark
  • Home, PA
  • Pharmacy
  • Full time
  • Day (United States of America)

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This job provides administrative direction/oversight to key strategic pharmacy operational functions pertaining to Medicare, ACA, and CHIP business, regulatory audit functions,  prescription drug event management, oversight of delegated vendor functions, and submission accuracy and pharmacy claims review, analysis and testing. Participates in the development, institution and oversight of policies, procedures and requirements as specified by regulatory standards. Directs interaction/involvement in working with key Company/pharmacy department business partner associates. Participates with the Director of Government Pharmacy Services and Manager of Government Pharmacy Program in establishing and achieving department goals and objectives consistent with the strategic plan of the company.


ESSENTIAL RESPONSIBILITIES

  • Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary. Empowered to make budgetary decisions impacting Pharmacy Medicare Operations.
  • Manage all aspects of Pharmacy audit activities that fall within the federal and state regulatory space Audit activities include, but are not limited to, leading pharmacy audit discussions with 3rd party audit entities to establish requirements and timelines for delivery, developing and delivering pharmacy data requests, managing pharmacy subject matter experts to conduct research and respond to findings, execute remediation activities and corrective actions for future prevention, and provide financial calculations for payment differentials. Empowered to issue corrective action plans in partnership with Government Compliance to internal and external stakeholders to remedy any issues identified during an audit activity. Direct involvement with operational audit reviews and model audit rule assessments.
  • Manage the development, implementation, execution and measurement of vendor delegated tasks involving high compliance, member experience, or financial risk. Maintain a working understanding of reimbursement methods, policies, and fee schedules as required to effectively meet and exceed strategic and tactical objectives. Partner with Pharmacy Vendor Contract team to address vendor performance issues impacting government business and to resolve member issues or complaints.
  • Direct staff to handle Gov’t Pharmacy operational functions that support the Federal Markets P&L such as claims processing, COB, fraud waste and abuse, prescription drug event, STARS measures, encounter risk adjustments and delegated vendor functions. Provide subject matter expertise to develop advanced analytics to enhance Pharmacy Government Program management.
  • Other duties as assigned or requested.


EDUCATION


Required

  • Bachelor's Degree in Business, Management, Administration, Finance, Accounting or related field


Substitutions

  • 6 years of related and progressive experience in lieu of Bachelor's degree


Preferred

  • Master's in Business Management

EXPERIENCE


Required

  • 5 years of relevant, progressive, and continuous experience within managed care, government markets, and/or pharmacy operations or audit role. 
  • 3 years in a leadership or management role


Preferred

  • Experience supporting operational functions for Medicare and ACA business


SKILLS

  • Proficiency in Software Applications including Microsoft Office Suite
  • Superior Organizational skillset with the ability to multitask, prioritize, and reprioritize work
  • Team building, facilitation, negotiation, and conflict resolution
  • Superior verbal and written communication skills
  • Presenting, leading meetings and developing senior leadership reporting
  • Medicare Advantage Part B &D/Medicare Part D (MAPD and/or PDP)
  • Operational background
  • Process Improvement (Six Sigma/Agile Practice)

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.


As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.

For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice


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