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Medicare Part D Specialist is responsible for coordinating and performing Medicare Part D oversight and monitoring activities with both external delegated entities and internal staff to ensure the Martin’s Point program is complaint with CMS regulations. As the primary coordinator for audits and comprehensive program management of Part D programs, this position also coordinates member-centered activities related to the Medicare pharmacy and Stars programs. This position works with internal and external parties to ensure resolution of member pharmacy needs and appropriate oversight of pharmacy customer service. This individual also coordinates member plan communications and member outreach related to the Medicare Stars program with appropriate internal parties.

Key Outcomes:

• Serves as Medicare Part D subject matter expert for the organization.
• Coordinates and participates in formal and informal Medicare Part D audits (internal and external).
• Responsible for review, completion, and oversight of all CMS related Medicare Part D member facing program materials (model documents, EOB’s, member letters, etc.) to ensure accuracy and completeness.
• Reviews oversight reporting provided by Pharmacy Benefit Manager (PBM) to ensure timely compliance with all CMS Part D related rules and regulations (transition fill claims, rejected claims, etc.) and reports findings to internal partners, committees, or audits as needed.
• Works with Pharmacy leaders to ensure ongoing reconciliation of reported Prescription Drug Event (PDE) errors, Coverage Gap, and other key processes with CMS and its contracted vendors, the PBM and internal departments.
• Documents and triages escalated Medicare plan pharmacy benefit related calls and collaborates with Member Services, Sales, and other Health Plan staff to research and respond to Part D benefit related questions or grievances, involving PBM or other internal parties as needed.
• Serves as primary contact for external agencies to coordinate member benefit information, such as Low-income subsidy (LIS).
• Coordinates Part D benefit training for plan staff with regard to annual Medicare program pharmacy benefit changes and on an as needed basis as Part D training needs arise.
• Develops policies and procedures, standard workflows, and reference materials to ensure standards are met and to ensure proper steps for performing tasks/functions can easily be followed.
• Responsible for oversight and monitoring of PBM Part D call centers, including monitoring metrics and quality performance and engaging PBM in continuous improvement activities.
• Coordinates member outreach activities and messaging related to Stars program and other member plan communications in collaboration with Quality and other internal departments.
• Provides and completes assignments for special projects which may include compiling of information, report generation, and maintenance of necessary records and files.
• Performs cross-functional tasks of other pharmacy team members and benefit related lines of business, such as USFHP.

Education/Experience:

• Associates Degree or combination of relevant education and experience
• 3 years customer service experience required
• Experience in operations, data analysis, or program development related to health care required
• Managed Care, Health Plan, and Part D benefits/program experience preferred

Required License(s) and/or Certification(s):

• Active Pharmacy Technician License in Maine a plus

Skills/Knowledge/Competencies (Behaviors):

• Demonstrates an understanding of and alignment with Martin’s Point Values
• Familiar with PBM on-line data entry, pharmacy locator and reporting systems
• Knowledge of Medicare Part D regulations, health plan operations, PBM operations, and best practices preferred
• Strong interpersonal skills and the ability to collaborate with internal and external clients
• Excellent customer services skills
• Superior written and verbal communication skills
• Ability to be flexible with changing priorities and work in a fast-paced environment
• Applies proactive and innovative solutions to improve process effectiveness when appropriate
• Solid analytical skills
• Ability to reconcile financial reports and data
• Strong mathematical ability
• Knowledge of PBM third party billing, pharmacy claims processing, and pharmacy data management
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint)
• Strong organizational skills
• Self-motivated with ability to manage, prioritize and complete multiple projects in a timely fashion with limited supervision
• Takes appropriate initiative while soliciting input/advice
• Ability to handle confidential and sensitive information in a discreet and professional manner

There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

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We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]