Clinical Pharmacist, Medicare Quality and Audit Support
Location: Schau! mburg Illinois
Description: Catamaran is presently looking of Clinical Pharmacist, Medicare Quality and Audit Support right now, this occupation will be placed in Illinois. Detailed specification about this occupation opportunity please give attention to these descriptions. Overview:
Job Summary
The Clinical Pharmacist serves as the primary clinical support for Catamaran's CMS audit support team. The Pharmacist works with clients, audit support and internal teams to investigate and respond to clinical questions encountered during CMS audit activity. They also work with internal teams to define, develop and implement clinically oriented, operationally focused oversight reporting and programs based on CMS guidance and best p! ractice notifications.
To perform this job successfu! lly, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Responsibilities:
Essential Job Functions
- Assist the audit support teams with the initiation, progression and completion of CMS client audits
- Assist the audit support teams with the tracking, escalating and resolution of all CMS audit action logs and deliverables
- Coordinate and lead the appropriate internal teams to provide direct clinical support and responses during all CMS, mock and internal audit activities
- Develop clinically based policies and procedures for inclusion in audit protocols
- Assist in the production of audit related dashboards
- Provide clinical insights and recommendations for audit post morte! m analysis and process improvement projects
- Create and provide clinical guidance for all operational oversight reporting needs
- Coordinate the development and implementation of all drug database source file validations
- Work with the Medicare Formulary, Benefit Administration, Product and Operations teams to ensure all clinically based program enhancements and updates are documented and incorporated into audit protocol as required
- Assist with oversight reporting and claims analysis/review as required
- Create clinical oversight presentations for management meetings
- Assist in clinical program and formulary implementation for new clients as needed
- Act as a clinical SME for all Medicare Quality initiatives and Sig Sigma process improvement projects
Qualifications:
Knowledge, skills and abilities (including core competencies)
- Essential skills include excellent written and verbal s! kills, decision-making, organizational and interpersonal skills, planni! ng and project management skills
- Ability to speak and effectively communicate with team members, management, clients and CMS auditors
- Ability to effectively present information and respond to questions from internal resources, managers, clients and CMS auditors
- Ability to work efficiently and effectively to manage and deliver on tight deadlines
- Ability to develop an expertise and working knowledge of the Catamaran formulary build/set-up, benefit administration, prior authorization and claims adjudication processes
- Ability to read, analyze, and interpret NCPDP standards, RxClaim adjudication logic and CMS Medicare Part D guidance and regulations
- Ability to read, analyze, and interpret general business periodicals, professional journals, and technical procedures
- Ability to develop and execute project plans
- Candidate will possess a general working knowledge of Microsoft Access, Excel, PowerPoint and Visio !
- Ability to obtain and maintain industry recognized and required credentialing in auditing and compliance
- Ability to maintain professional licensure credentials
- Ability to work days, nights, weekends and holidays as required
- Ability to travel up to approximately 25% as required
Education and experience
- Bachelor’s degree in Pharmacy, Doctorate of Pharmacy (PharmD) preferred with residency training or equivalent experience
- Current state pharmacy license in good standing
- 3-5 years Medicare Part D formulary and/or benefit administration development experience
- 2-3 years experience in a PBM/managed care clinical role, creating clinical programs and reporting
- CMS audit experience preferred
- Project management experience preferred
- Medispan and FDB drug file experience preferred
- Data analysis and claims research experience preferred
- Certified! Healthcare Auditor (CHA) or Certified in Healthcare Compliance (CHC) p! referred
- Six Sigma experience (yellow/green/black belt) preferred
- Familiarity with RxClaim, NCPDP claims adjudication standards and pharmacy practice preferred
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If you were eligible to this occupation, please email us your resume, with salary requirements and a resume to Catamaran.
If you interested on this occupation just click on the Apply button, you will be redirected to the official website
This occupation starts available on: Sat, 15 Feb 2014 14:32:19 GMT
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