Remote Utilization Review Jobs in Portland, ME (NOW HIRING)

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Position Summary
 The Pharmacy Benefits Specialist is responsible for coordinating activities between MPHC and our Third-Party Administrator, Pharmacy Benefit Manager (PBM) and supporting program initiatives. This position works collaboratively with internal and external parties to ensure that contractual pharmacy benefit and reporting requirements are met. The Pharmacy Benefits Specialist is responsible for monitoring appropriate channels for pharmacy program benefit changes and alerting the appropriate individuals of those changes and for providing training to plan and delivery system staff on pharmacy benefits and systems.
Job Description

PRIMARY DUTIES AND RESPONSIBILITIES

• Documents and triages all plan pharmacy benefit related calls, enters Prior authorizations into PBM/ pharmacy systems and ensures accuracy of plan design in PBM and pharmacy systems.
• Serves as USFHP Pharmacy Guidance subject matter expert
• Participates in system configuration and end-to-end testing of pharmacy benefits during implementation or benefit changes.
• Provides quality assurance and testing related to plan set up and ensure all coding has been done appropriately.
• Provides training to pharmacy and plan staff with regards to functionality of PBM and pharmacy systems.
• Develops and updates benefit-related training materials, job aids, and FAQs for internal teams and assists in development of provider education materials regarding formulary changes, utilization management processes, or pharmacy updates.
• Responsible for verifying accuracy of plan design in Pharmacy and PBM systems and working with appropriate individuals to develop corrective action plans for identified problems.
• Provides and completes assignments for special projects which may include compiling of information, report generation, maintenance of necessary records and files.
• Develops procedures and reference materials to ensure standards are met and to ensure proper steps for performing tasks/functions can easily be followed.
• Responsible for review and follow-up on DoD fatal error reports.
• Works with departments throughout MPHC to ensure eligibility related updates are made to Pharmacy and PBM systems.
• Develops and maintains processes and workflows for handling of USFHP member overrides through PBM system.
• Coordinates with PBM to ensure consistent procedures for handling of customer/member service calls
• Research and coordinates responses to member complaints with MPHC mail order pharmacy and other internal and external parties
• Partners with internal and external teams to analyze pharmacy utilization trends and drive cost-saving initiatives for USFHP that align with organizational priorities, DoD guidelines, and TRICARE regulatory requirements.
• Supports internal or external audits (CMS, DoD, NCQA, DHA) by compiling documentation, preparing evidence packages, and responding to findings.
• Supports pharmacy quality improvement initiatives and performance measures, including HEDIS, Medicare Star Ratings, and other regulatory and quality programs, through member outreach, provider engagement, intervention tracking, and gap closure activities.
• Collaborate with cross-functional teams to support NCQA accreditation and reaccreditation activities, including policy reviews, evidence collection, reporting, process improvement initiatives, and audit readiness efforts.
• Participates in the annual Medicare Part D plan year implementation process, including benefit configuration, system testing (UAT), and validation of plan design accuracy within PBM, Medicare Part D Specialists and internal systems.
• Supports the Medicare Part D Specialist by assisting as a backup during periods of absence or high-volume completing duties including, but not limited to, regulatory monitoring, member materials oversight, and CMS-related tasks when needed.

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

POSITION QUALIFICATIONS

Education:

• Associate's degree or combination of education and relevant experience

Experience:

• 2+ years of administrative, business or other relevant experience required.
• Healthcare benefit or Pharmacy Technician experience preferred.

Knowledge:

• Knowledge of medical terminology, generic/brand name drugs.
• Knowledge of PBM third party billing.

Skills:

• Excellent customer services skills.
• Effective communication skills (written, verbal, interpersonal).Solid analytical skills.
• Strong organizational skills (ability to prioritize and multi-task while maintaining focus on objectives).
• Strong interpersonal skills and the ability to collaborate with internal and external clients

Abilities:

• Strong mathematical ability.
• Ability to reconcile financial reports and data.
• Ability to function independently with sound judgment in decision making.
• Take appropriate initiative while soliciting input/advice appropriately.
• Ability to handle confidential and sensitive information in a discreet and professional manner.

Pay Range: $25.33 - $31.29 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan.
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org

Do you have a question about careers at Martin's Point Health Care? Contact us at:jobinquiries@martinspoint.org