Pharmacy Services Vendor Specialist at Independence Blue Cross LLC in Philadelphia, Pennsylvania

Job Description:

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.

The Pharmacy Services Vendor Specialist responsibilities includes:

• Investigate and provide root cause analysis, impact and issue remediation for compliance issues.


• Review supporting documentation to ensure that key OMT indicators identifying compliance are met.  


• Provides direction regarding next steps of issue(s) identified such as letter language, Rx authorization overrides, member outreach etc.


• Provides direction for member resolution which includes but is not limited to reimbursements, letter generation, Rx overrides, Rx Grandfathering etc.


• Support the daily DPR process to identify adjudication issue and escalate appropriately. 


• Support weekly compliance issue resolutions meeting to ensure closure (Kathy’s team, delegation oversight, PBM.  Provide direction to PBM on next steps how to address errors or issues (i.e.., reprocessing claims, etc.) 


• Provides final approval to release reprocessed claims (notify PBM).


• Collect and validate data to support audits. (Internal, NCQA, CMS audit, self-funded).


• Collect and validate data to support external vendor audit request to comply with format and audit timeframes. 


• Coordinate with the PBM regarding audit requirements, PBM provides data, this role reviews the request against what comes back from PBM.  If not accurate, goes back to PBM.  If accurate, release the data


• Report PBM performance within the performance guarantee process.  (monitor for the month the PBM performance guarantee.  Track and trend metrics and documentation.


• Conducts daily coverage determinations timeliness review.


• Conducts daily coverage determination letter QA to ensure accuracy. (letter generated at PBM and ensuring the compliance oversight of letter).


• Escalate all findings with recommendations and outlining compliance risks.  (looking at report of work from PBM the prior day, verifying the work was accurate and compliant.   If not, identify, determine regulations, identify what failed and outline compliance risks)

QUALIFICATIONS:

Education

• Bachelor’s degree or equivalent work experience

Experience

• 3+ Years related work experience

Knowledge, Skills

• Medicare and/or health plan operations experience preferred


• Audit experience


• Pharmacy Background preferred

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Independence has implemented a “Hybrid” model which consists of Associates working in the office 3 days a week (Tuesday, Wednesday & Thursday) and remotely 2 days a week (Monday & Friday). This role is designated as a role that fits into the “Hybrid” model. While associates may work remotely on our designated remote days, the work must be performed in the Tri-State Area of Delaware, New Jersey or Pennsylvania

Equal Employment Opportunity

Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. 

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