Job Description

Supervisor(a) de Determinaciones de Farmacia

Regular


Exempt

GENERAL DESCRIPTION:

Responsible for the management of the Pharmacy utilization management drugs unit for all the company's business lines. ensure that the evaluations of clinical pre-authorizations conducted by their team are based on established criteria approved by the Pharmacy Benefit Management (PBM), the Pharmacy and Therapeutics Committee (P&T), the company's Medical Committee, and relevant guidelines from regulatory agencies such as the Centers for Medicare and Medicaid Services (CMS), the Puerto Rico Health Insurance Administration (ASES), and the Office of the Commissioner of Insurance (OCS), among others. Responsible for the implementation and execution of initiatives related to specialty medications.

ESSENTIAL FUNCTIONS:

Assists in ensuring compliance with the payment rules set for any J codes, GPI, or NDC that require evaluation through a Utilization Management (UM) edit. This process is used to review the drugs billed by the unit to modify or add utilization edits as necessary. Assure all drug requests are managed as per the Regulation time frame, priorities, and rules required. Implements and oversees initiatives related to all medications with utilization management edits that impact operations and drug trends, as requested, and provides recommendations to the Formulary Teams if any findings are observed. Ensures and guarantees that the unit meets the standards established by regulatory agencies or clients through their contractual arrangements. Develops reports to monitor errors on tools such as request reason fields, terms date fields, mailing vendor completion fields, oral notifications, and any fields that are required to be completed accurately on the unit platform. Assist in revising or developing the policies and procedures (P&P) and operational guides necessary to ensure operations are managed in compliance with regulations and are well-organized. Monitors the volume of calls and requests received at the unit, ensuring that the personnel under their supervision comply with the established service standards, such as the percentage of calls answered. Ensures the personnel under their supervision meet the established indicators, which include productivity based on the specified percentage related to the business line results, adherence to the assigned itinerary according to the designated percentage, and maintenance of service quality following the established standards. Ensures that the personnel under their supervision properly handle the work tools according to the service and quality standards established by the department. Handles sensitive situations presented by clients with other departments and responds to internal inquiries received from other departments. Responsible for designing, implementing, and maintaining metrics to evaluate the performance, efficiency, and quality of the unit's processes, products, or services. Report metrics to evaluate tendencies and compare it with previous month or year as needed to finally establish initiatives to manage the volume or any flag observed on it. Supervises, monitors, trains, evaluates, and corrects personnel among others to comply with his/her role as a supervisor, to assure that his/her personnel fulfill their work plan and comply with their essential functions and that they behave following the policies, standards, norms, and procedures of the Company. Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience:

Associate Degree in Pharmacy Technician. At least three (3) years of pharmacy experience, performing data analysis and drug approval, preferably in a Call Center, Healthcare Insurance Industry, or PBM. At least one (1) year of experience supervising staff.

Certifications / Licenses:

A valid Pharmacy Technician license and registration is required.

Other:

N/A

Languages:

Spanish - Intermediate (comprehensive, writing and verbal)

English - Intermediate (comprehensive, writing and verbal)

"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Accion Afirmativa para reclutar a Mujeres, Minorias, Veteranos Protegidos y Personas con Impedimento

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