Pharmacy Programs Specialist
Core
Support Medicare quality metrics, medication management initiatives, and CMS compliance through claim validation, telephonic outreach, and data analysis for plan members and providers.
Role type
Mid-level pharmacy programs specialist (managed care)
Builds
Part D Star measures, medication management programs, and operational efficiency for Medicare Advantage plans
Domain
Healthcare / Pharmacy Benefits Management (PBM) / Medicare Part D
Deliverable
production ML models | product features | dashboards & analysis | client delivery
Required skills
Pharmacy operations, claim adjudication validation, telephonic outreach, data analysis, regulatory compliance (CMS), process improvement, cross-functional collaboration, root cause analysis, training delivery, quality assurance
Preferred skills
National Certification (CPhT) Pharmacy Technician License, managed care experience, Windows-based applications proficiency
Technologies
Windows-based applications, Clover Health platforms, PBM delegated functions tools
Responsibilities
Validate claim adjudication to ensure appropriate access to care; conduct telephonic outreach for plan members, providers, and pharmacies; contribute to improving Part D Star measures by resolving medication management issues; collect and present data trends to propose process improvements; provide guidance on pharmacy clinical and regulatory workflows; organize pharmacy team meetings; lead educational training on Part D knowledge and vendor platforms; perform call center quality assurance reviews; generate reports to improve clinical pharmacy quality metrics; file, review, and validate reports for Medicare compliance.
Seniority
Mid-level, hands-on IC with program/project ownership