The selected candidate must have 5+ years experience in Medicare Part D and/or EGWP programs.
Scope of Responsibilities: Provides oversight and management of Medicare Part D/EGWP program.
Job Summary: The position will be the operational subject matter expert for administration of EGWP programs through ProAct. Responsibility for the understanding and compliance of benefit designs, system management of formularies, eligibility, claims and payment, reconciliation, and quality control. Coordination with Plan Sponsor to ensure program is compliant with Medicare Part D standards and consistent with ProAct client benefit. Aid internal teams to support clients and business partners.
ResponsibilitiesProvide oversight of operational activities of Medicare Part D/EGWP programsEnsure compliance with CMS rules and regulations surrounding Medicare Part DSupport vendor relationships (e.g. Plan Sponsor), daily operations, and implementation of EGWP pharmacy programsUnderstand service agreements and terms between ProAct and vendor partners (e.g. Plan Sponsor) and clientsAct as primary point of contact for Plan Sponsor contracted to administer programsUnderstands benefit build, eligibility, enrollment, formulary, claims processing, clinical, files management, reporting, and other components of EGWP programsCoordinate with implementation teams to ensure accurate benefit build and claims processingResponsible for supporting inquiry/issue/escalation resolution Oversee resolution of prescription drug event (PDE), eligibility, or other issues that are necessary for EGWP programsMaintain understanding and compliance with current on rules and regulations pertaining to Medicare Part D/EGWP programs Evaluate potential impact and applicability of new or changed rules and/or regulationsIdentify performance and compliance risks and communicates to leadership and/or others in a timely manner to minimize non-complianceReview new guidance, memos, and regulations and create and adjust internal policies, processes, and/or procedures appropriately. Communicate changes to leadership and/or others as required.Supports collaborative relationships with internal and external teams or partners to determine best practices, efficiencies, or process improvements that enhance program performance and member experience.Partner with other departments or business units to grow, develop, and enhance EGWP programs and opportunitiesAssist in creation of member and client materials ensuring consistent with CMS regulationsSupport client service teams with presenting analytics or other reports to clients and/or business partners Qualifications
Job Skills Required:
Excellent oral and written communication skillsAbility to create and conduct effective presentationsProblem solving and analytical skillsStrategic and creative thinkerStrong organizational skillsSelf-motivated with ability to prioritize multiple tasks along with a strong sense of urgency and responsivenessProficient in Microsoft Office and AdobeUnderstanding of PBM and/or TPA industry, preferredEducation:Minimum: High School Diploma (or currently enrolled) or GED Preferred: BS Degree in Business or similar
Experience:
5+ years experience in Medicare Part D and/or EGWP programs
Special Conditions of Employment:
Drug testInitial and continuous exclusion and sanction/disciplinary monitoringAny and all additional eligibility requirements based on the specific position
Compensation
$60,000 - 73,000 per year.
The final offer will be determined after careful consideration of multiple factors such as relevant skills, years of experience, and education.
KPH Healthcare Services, Inc. is a multistate organization and abides by all local, state, and federal regulations as it pertains to minimum wage requirements.
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