Manager Utilization Management Jobs in Washington

Description

Summary:

The Pharmacy Benefit Coordinator is responsible for supporting clinical outreach services to our members, their pharmacies, and their healthcare providers to ensure member safety, minimize gaps in care, identify cost-effective medication strategies, and coordinate care to improve healthcare outcomes for our members. The position will support HEDIS adherence initiatives and work to support longitudinal improvement goals.

In addition, the Pharmacy Benefit Coordinator performs a variety of routine to moderately complex administrative and pharmacy-related tasks that support the Pharmacy Management team within the department. The Pharmacy Management team is responsible for managing the pharmacy benefits for Maryland Physicians Care in collaboration with the pharmacy benefit management (PBM) vendor and the organization's utilization review, quality improvement, provider relations, and population health initiatives.

About Maryland Care Management, Inc. (MCMI)

Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care's (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD's largest Medicaid-managed care organizations.

Why join us?

MCMI recognizes the importance of flexibility and offers multiple work arrangements. Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans.

Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed. We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to impact our members' lives positively.

What You'll Do:

• Work collaboratively with quality management to support HEDIS adherence projects.
• Support the accurate implementation and coding of pharmacy benefits, formulary, and program changes, including review of PBM testing scenarios.
• Review pharmacy services recommended for denial. Of those recommendations, investigate and review data and information retrieved from plan providers.
• Assist in the management of members by collecting pertinent information from plan providers and other pharmacy data systems.
• Assist in various pharmacy, utilization review/management, quality improvement, provider relations, and population health initiatives.
• Serve as a pharmacy liaison and resource person to plan pharmacies and members.
• Assist the Pharmacist with monitoring and evaluation of pharmacy utilization.

Requirements

Knowledge and Skills:

• Thorough understanding of prescription benefit management (PBM) programs and practices.
• Ability to identify, communicate findings, and resolve member, provider, process, and system issues, communicating recommendations verbally and in writing.
• Business writing and presentation skills, including writing reports.
• Excellent attention to detail, including but not limited to interpretation and understanding of benefits/codes.
• Familiarity with government relations and the ability to operationalize and understand how various aspects of regulation are interdependent and related.

• High School diploma/ GED, or equivalent.
• Current Maryland State Pharmacy Technician licensure, including certification from a nationally recognized Pharmacy Technician Certification Board.
• Minimum two (2) years of experience as a pharmacy technician.
• Experience working in a managed care, insurance, PBM, or equivalent environment is strongly preferred.
• Experience supporting utilization management/prior authorization processes.

EEOC Statement: Following applicable federal, state, and local laws, MCMI prohibits discrimination in employment based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, or any other characteristic protected by law. This commitment extends to all aspects of employment, including hiring, promotion, compensation, benefits, training, social and recreational programs, and all other conditions and privileges of employment. As a healthcare organization, we recognize the vital importance of inclusivity in delivering quality care to our patients. We strive to foster an environment where individuals of all backgrounds feel respected, valued, and supported. We aim to better comprehend the unique needs of our patients and provide healthcare services that are culturally competent and sensitive. We encourage candidates from all backgrounds to apply and join us in our mission to provide compassionate and inclusive healthcare. We believe that a diverse workforce enriches our organization and allows us to better understand, connect with, and serve our diverse patient population.