40 Health Plan Member Services Representative Jobs Hiring Near You

THIS IS NOT A REMOTE POSITION - Required to work in Wheeling - Hybrid.

Responsible for comprehensive knowledge of current pharmacotherapeutic principles, disease state and population management to help ensure the delivery of safe, appropriate, and cost-efficient pharmaceutical care to membership.

Required:

1. Doctorate of Pharmacy or Bachelor of Pharmacy degree with active and unrestricted license in good standing as a registered pharmacist by a Board of Pharmacy in the U.S. prior to or within 90 days of hire date. Should have demonstrated compliance with licensure and Board of Pharmacy continuing education policy throughout hire.
2. Possess strong communication, complex problem solving, critical thinking, judgement and decision making and time management skills.
3. Ability to complete accurate and detailed supporting documentation of utilization management decisions, medication reconciliations and medication reviews.
4. Ability to work independently and carry out assignments to completion without direct supervision.
5. Flexibility, ability to multi-task, work in a fast-paced environment, adapt to changing processes and prioritize assignments appropriately.
6. Ability to work as a team member.
7. Follow all plan policies and procedures.
8. Possess demonstrated knowledge Microsoft Office programs for business (i.e. word processing and spreadsheet applications) with proficient keyboarding and computer literacy skills and the ability to navigate multiple systems

Desired:

1. Doctorate of Pharmacy.
2. Experience in managed care pharmacy.
3. Pharmacy residency (managed care residency preference).
4. Advance training (certified) in disease state management (i.e. diabetes, immunizations).
5. Experience with government programs.
6. Board of Pharmacy Specialties certification.
7. Medication therapy management experience.
8. Experience with medication reconciliation and review.
9. Experience participating on Interdisciplinary Care Teams in a managed care or healthcare setting.

Responsibilities:

1. Remain continually updated regarding new products, indications, and industry trends.
2. Develop and present new drug policies for P&T Committee review.
3. Collaborate with The Health Plan physicians, pharmacists, nurses, and other related staff to perform utilization review of drugs for the development of drug policies including researching new drugs for possible utilization management and providing education to staff pertinent to these policies.

1. Review drug/medical literature, clinical practice guidelines, and available national guidelines to support drug policy development and consultation over various medical and pharmacy clinical programs.
2. Attend CM/UM case conferences with the CM/UM nurses and Medical Directors.
3. Provide clinical support for the administration of pharmacy benefits.
4. Meet internal key performance indicators as defined by applicable The Health Plan Policies & Procedures.
5. Attend on site Interdisciplinary Care Team meetings as needed for assigned/attributed members 
6. Document and complete peer-to-peer requests when needed. 
7. Complete documentation of appeal notes for Medical Director decisions when necessary. 
8. Communicate identified cost assistance issues to the benefit assistance member advocate. 
9. Communicates any identified quality of care issues to Quality Improvement.
10. Communicates any identified fraud, waste, and abuse issues to Special Investigations Unit.
11. Review cases referred from Quality Improvement or Special Investigations Unit. 
12. Use appropriate documentation to meet National Committee for Quality Assurance (NCQA) and Centers for Medicare and Medicaid Services (CMS) standards.
13. Adjust workflows in response to audit findings.
14. Complete pharmacy utilization management coverage determinations in accordance with The Health Plan Productivity Standards.
15. Cross train to perform functions and responsibilities of a care management pharmacist. 
16. Complete care management pharmacist functions during seasonally high periods or for vacation/sick day coverage.
17. Identify new opportunities for drug management, including safety programs, and medical/pharmacy cost savings.
18. Provide relevant drug information to both in-house staff and membership upon request.
19. Conduct and document comprehensive medication reviews for eligible members of the MTM program.
20. Work as a part of an integrated team with clinical department to close gaps in care, reduce readmissions, and provide better quality of care at the right time, place, and cost to improve outcomes.
21. Maintain updated knowledge base regarding federal, state, NCQA, or other oversight bodies to meet standards.
22. Assume leadership role representing the department in activities or projects as assigned by pharmacy management.
23. Write internal utilization management or operational polices when needed.
24. Write internal operational workflows when needed.
25. Review and update internal Health Care Common Procedure Coding System codes authorization and coverage status.
26. Review West Virginia Bureau for Medical Services policies for coverage alignment. 
27. Review and update internal utilization management policies received from pharmacy benefit manager. 
28. Assist account managers with pharmacy related questions. 
29. Support after hours staff in appropriate pharmacy decision-making and support to members and providers. 
30. Registered Pharmacists are responsible for reporting any changes in licensure status (e.g., application declined/denied; license revoked/suspended or lapsed; notification of an investigation by licensing board; becoming subject to disciplinary action by a licensing board) to their direct supervisor throughout their term of employment.

Equal Opportunity Employer

The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.