BlueCross BlueShield of Western New York

About BlueCross BlueShield of Western New York



United States

Postal Code:


Approximate Salary:

Not Specified

Position Type:

Full Time

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Pharmacy Operations Specialist

Posted: 09/10/2018

Auto req ID 1859BR Company BlueCross BlueShield of WNY About Us BlueCross BlueShield of Western New York is a division of HealthNow New York Inc., one of New York’s leading health care companies that provides access to quality health care and solutions for members throughout Upstate New York. Since 1936, BlueCross BlueShield has helped millions of people gain access to health care. Headquartered in Buffalo, NY, the company is an independent Licensee of the BlueCross BlueShield Association. As the region’s leading health plan, serving over 800,000 members, BlueCross BlueShield believes in taking small steps towards healthier living. You can visit our website at Title Pharmacy Operations Specialist Position Posting Location Buffalo Status Full Time Regular Hours 40 Job Description Responsible for developing and maintaining the operational and customer servicing day to day relationship and processes between HealthNow and the PBM which ensures timely and accurate transactions for more than 500,000 HealthNow members with a pharmacy benefits. Individuals in this role provide accurate coding to support over 6 Million claims transactions as well an average of 400,000 service calls per year. Accurate and efficient development and oversight of these transactions supports the Pharmacy Services Team to manage a $500 - $550 Million Dollar drug spend which contributes to 30 - 50% of HealthNow's affordability agenda. This position reports directly to the Manager, Pharmacy Operations. Primary Responsibility Responsible for maintaining effective operational transaction processes between HealthNow and the PBM as well as day to day internal operational transactions related to HealthNow’s pharmacy benefit. This includes the responsibility of key contact for day-to-day issues between HealthNow and the external PBM. Participates and/or leads PBM implementation teams facilitating the implementation process to the PBM to achieve a successful implementation. Acts as SME for Pharmacy, ensures proper coordination with Medco. Defines system logic definition to IT and PBM which allows the transfer of FACETS data such as product id, pdbl and pdbcs to be interfaced into a program which will accommodate the PBMs system specifications to support eligibility, benefit and encounter data processes. This includes but is not limited to system enhancements, benefit changes, new benefit designs and State and Federal Mandates. Leads and performs testing process, ensuring the accurate connectivity between FACETS and the PBM’s system. Demonstrates excellent ability to coordinate unit testing and to manage documentation of definition and testing outcomes. Investigates, resolves, and communicates problems that are complex and difficult in character that affect the accurate and timely processing of claims, membership transactions, interfaces, and/or reports by the PBM. Defines and maintains FACETS system logic definition to support CPT codes related to claims adjudication. Serves as internal primary point of contact for all PBM, pharmacy benefit, systems, claims, edits and operational and customer service inquires. Troubleshoots, evaluates, educates, researches and provides resolution and/or guidance in regards to such inquiries. This includes direct or indirect resolution for all SBUs, Brokers, Groups and Executive inquiries related to the pharmacy benefit. Monitor the Eligibility Transmission Process which includes the resolution of errors posted to the PBM/HealthNow Pre Edit Report related to pharmacy benefit configuration. Responsible for mentoring and training both the Pharmacy Services staff and PBM Account Team as assigned and as applicable on new products, processes and/or changes to existing products or processes. Works with Account Executives and Account Support Team to develop and deliver accurate pharmacy benefit designs based on group specifications. This includes interpreting previous pharmacy benefit designs as outlined in the groups SPD and converting them into HealthNow specific designs. In addition, the Specialist is responsible to provide benefit inclusion, exclusions and limitation documentation to support the development of the group’s HealthNow SPD. Possesses and applies a broad knowledge of principles, practices and procedures to coordinate the implementation of new products, new procedures, and changes to existing products and procedures that impact the PBM, and to coordinate interaction between all HealthNow divisions/departments and the PBM. Identifies and implements process improvements that relate to the relationship between HealthNow and the PBM. Maintains a close relationship with SBU leaders in regards to Customer Service. This includes developing Standard Operational Procedures in regards to HealthNow/PBM customer service workflows, providing or creating documentation and/or training materials to support the accurate interpretation of the pharmacy benefit and efficient processes. Creates ad hoc reports using Medco's ad hoc data analysis tools to assist with claim performance and benefit analysis. Assists management with special projects. Performs other related duties as required. Knowledge and Skills Strong organizational and project management skills are required. The incumbent must be able to function in a complex, multi-functional team environment. Exemplary written and verbal communication skills are required. Strong PC skills, including word-processing, Microsoft Access, and Facets. Strong analytical skills are required to resolve problems. Qualifications Problem Solving Skills: Must be able to identify and diagnose problem areas, recommend solutions, and document and present changes and enhancements.
External Contacts: Employer Groups, Brokers, Pharmacy Benefit Manager
Experience Degree or a minimum of 3 years of progressively responsible experience in the health insurance field, with experience in pharmacy. Vendor relations and/or project management experience preferred. Education Required Education:Bachelors Degree (N/A) EEO Statement All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status. Removal Date 19-Jun-2019

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