PDP Program Associate

PDP Program Associate

Requirements

• Associates degree (or equivalent combination of education and experience) with 5+ years’ related experience.
• Prior experience in the PBM, pharmaceutical, or healthcare or health & welfare insurance industry required.
• Intermediate to advanced knowledge of MS Project, Visio Project Management software and Microsoft Office Suite software.
• Knowledgeable in responding to CMS guidance changes.
• Good understanding of Part D processes within cross-functional teams.

Responsibilities

• Responds to client emails including Grievances and Salesforce cases in a timely fashion.
• Works closely with internal client and implementation teams in reviewing test claim results.
• Maintains a superior knowledge of the plan designs and benefit setups for clients as well as the CMS benefit standard.
• Provides client-facing support for Project Implementation and/or internal implementation support including Sales/Account Management support for Business Development.
• Provides operational support for PDP programs and services.
• Takes inbound calls and places outbound calls to members and other external entities to assist with member issues, member collections, Grievances, COB (Coordination of Benefits) notification and other member communications.
• Researches client or member issues related to the pharmacy benefit and provide resolution to internal and external customers including outreach to the pharmacy, facility and/or member.
• Research returned mail, logs outcome within internal systems, conducts member and pharmacy outreach to obtain updated information and mails out additional inquiries and/or mail pieces to the correct member address.
• Conducts denied claim review for all operational rejections and works with the member/pharmacy/client to resolve any issues.
• Creates and communicates task status to management and program managers.
• Creates policies and procedures and work instructions.
• Oversees and monitors related programs including True-up, FIR, COB, Hospice, ESRD, Excluded/Precluded Provider, OON, and Pharmacy Terminations along with any downstream processing including creation of all applicable reporting (in collaboration with other team members).
• Executes established SQL queries, extracting data from relational data bases and tables for purposes of audit support, issue identification and the generation of impact analysis.
• Provides ‘Data Validation’ Audit support by working with the vendor. Acts as a subject matter expert for CMS reports; serves as a liaison with external auditors.
• Monitors and ensures accurate claims adjudication for denied claims and post-implementation monitoring.
• Tracks any assigned issues that are communicated to CMS and presents findings and remediation to the plan sponsor.
• Mentors and trains less experienced employees within the department.

Preferred Qualifications

• Pharmacy Technician, preferred, not required.