**Hybrid Work Environment - Must reside in Hawaii **

Optimize Medicare member experience by identifying and performing process improvement initiatives.

• Support the pharmacy strategy from a Medicare benefit design and delivery perspective.
  • Maintain a deep understanding of Medicare benefits.
  • Work with internal HMSA staff to drive benefit design and delivery that will foster ideal member care.
    • Analyze business needs and data, develop feasible solutions, implement changes, and evaluate effectiveness of changes.
  • Work with external stakeholders such as the Pharmacy Benefit Manager (PBM) to operationalize benefits.
    • Collaborate with the PBM to provide the best benefit product/service.
    • Perform oversight of the PBM and other entities as applicable to ensure the benefit is provided as intended.
    • Implement, test, and evaluate changes made within the PBM

• Lead and support project management and communications.
  • Manage projects that coordinate and implement clinical initiatives and/or pharmacy benefit operations and improvements.
    • Conduct research, evaluation of measures and value assessments of initiatives and/or programs.
    • Assess compliance with Federal and State regulations, internal policies, procedures, and workflows.
    • Streamline workflows.
    • Review and edit requirements, specifications, business processes and recommendations related to proposed solutions.
    • Coordinate and facilitate planning, tracking, and installation of business requirements and deliverables.
  • Perform outreach as necessary to support pharmacy and quality strategies.
  • Provide quality, objective, and professional analyses of business needs and PBM capabilities/limitations.
  • Develop policy and procedures, work instructions, training materials, and employee training.
  • Develop communications as appropriate to facilitate ideal utilization of pharmacy benefits.

• Manage incoming Pharmacy Management inquiries with a superior level of customer service.
  • Coordinate problem solving associated with inquiries and follow through to resolution.
  • Identify root causes of individual and/or trending encounters and carry out process improvement initiatives.
  • Triage inquiries, if necessary, to ensure servicing needs are properly identified and addressed.

• Lead Medicare Point-of-Sale Operational Tasks.
  • Reconcile all benefit and coding related documents to ensure accuracy and timely updates as necessary.
  • Define acceptance testing criteria and ensure that the criteria are met before system changes are implemented.
  • Maintain PBM system functionality to ensure operational efficiency
  • Monitor and evaluate accuracy of pharmacy drug benefit through testing review and validations; report monitoring and/or live claim review.
  • Ensure HMSA meets performance standards stated by government regulations, employer groups, Blue Cross Blue Shield Association, internal policies, procedures, workflows and business requirements.

• Manage special projects as assigned.

• Performs all other miscellaneous responsibilities and duties as assigned or directed.