Supports daily operational functions and oversight of the SCAN Pharmacy Benefit Management (PBM) company on delegated Part D activities
Assists with maintaining compliance with Part D deadlines and regulatory timeframes
Provides support in managing Eligibility files, Prescription Drug Event (PDE) data, Drug Plan Finder submissions, Financial Information Reporting, and other key functions to help ensure adherence to Medicare requirements
Serves as a subject matter expert for Part D Reporting requirements, Pharmacy Access Requirements, Prescription Drug Event data, Financial Information Reporting and Drug Plan Finder files by keeping up to date with Medicare requirements
Ensures eligibility and coordination of benefit files are sent to the PBM for processing and assesses if file enhancements are needed
Ensures the PBM is processing Prescription Drug Events, Automated Claims Reprocessing and Financial Information Data according to CMS regulatory standards by conducting daily oversight
Ensures PBM oversight of claims adjudication and retrolics and ensures 1/1 Readiness related to eligibility
Analyzes and monitors large data sets that are exchanged from SCAN to the PBM using a variety of reporting tools
Ensures audit documentation is prepared according to audit instructions and provided within the specified audit time frame
Prepares written responses or documentation for pharmacy audits
Performs routine monitoring to ensure Part D compliance and detect performance issues or operational gaps
Assists in the implementation, testing, and validation of pharmacy benefits to ensure accurate benefit configuration and claims adjudication
Collaborates with cross-functional teams, including Compliance, Product, and IT, to address issues and support PDE and other pharmacy initiatives
Identifies and escalates issues related to pharmacy benefits, claims processing, and PDE submissions, working with the PBM and internal teams to resolve discrepancies
Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications & CMS regulatory requirements; establishing personal networks; participating in professional societies
Contributes to the development, maintenance, and documentation of standard operating procedures (SOPs) and desktop procedures to support compliance and operational efficiency.

Requirements

0-3 years of related experience
High School Diploma or equivalent experience required
Bachelor's Degree or equivalent experience preferred
Expert knowledge of CMS Part D regulations e.g., CMS Call Letters, MA-PD application, PDE, LICS, Claims Processing, Part D Reports, FIR
Knowledge of PDE calculations that pertain to Enhance Alternative Plans, Coverage Gap, etc.
Ability to prioritize workload to meet deadlines
Ability to multi-task in a fast pace environment
Ability to interact effectively and professionally with all levels of staff
Excellent grammar and writing skills
Excellent verbal skill sets to be able to communicate in conference calls and in large meetings
Team player with a strong work ethic
Self-starter that can take the lead on a project and manage its progress for completion
Detail oriented and is able to work with large data sets
Advanced skills with Microsoft Office (e.g., Word, Excel, Access, Outlook, and PowerPoint) and SQL
Familiarity with Tableau and Visio.

Benefits

An annual employee bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
11 paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
Excellent 401(k) Retirement Saving Plan with employer match and contribution
Robust employee recognition program
Tuition reimbursement
An opportunity to become part of a team that makes a difference to our members and our community every day!

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

CMS Part D regulationsPDE calculationsClaims ProcessingFinancial Information ReportingData analysisCompliance monitoringBenefit configurationClaims adjudicationAudit documentationStandard operating procedures

Soft Skills

Ability to prioritize workloadMulti-taskingEffective communicationTeam playerStrong work ethicSelf-starterDetail orientedExcellent grammar and writing skillsVerbal communication skillsCollaboration