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GENERAL DESCRIPTION :
Responsible for monitoring the execution of the measures of Medication Adherence Stars, Quality, Medication Therapy Management (MTM), Home Delivery of medications, and Diabetes Program, as well as referrals for home deliveries, among others of the pharmacies in the Pharmacy Quality Program. Establishes and develops action plans to improve patient adherence that impacts the Center for Medicaid and Medicare Services (CMS) five Stars Rating System (STARS). Implements the necessary initiatives to improve the service experience of our members in pharmacies to mitigate the effect of disenrollment and increase the rating of the STARS system.
ESSENTIAL FUNCTIONS :
- Establishes, discusses, and documents the Corrective Action Plans (CAPs) by Pharmacy as a required process. Monitors the effectiveness of the CAPs and compliance with the actions. Presents reports on the status of pharmacies in CAPs and adheres to the following recommendations.
- Maintains records of the CAPs, as well as all documentation that supports the process.
- Responsible for carrying out face-to-face visits to Pharmacy providers throughout different Puerto Rico locations. Accountable for contracting participating providers of the "Pharmacy Quality Services Program."
- Participates in developing initiatives to improve the Pharmacy services experience.
- Performs audits to comply with the Star and Pharmacy Quality Services programs.
- Provides training to providers on the tools available to prioritize the interventions of the Adherence Program and other tools used by pharmacies for the clinical management of the company’s patients. Educates providers on all issues related to Pharmacy Benefits and service tools.
- Alerts about situations and practices of the competition identified through its contacts with providers and pharmacies. Identifies situations referred by the pharmacies related to delegated functions of the Pharmacy Benefits Managers (PBMs) and channels them effectively with the corresponding area.
- Complies with documentation and collection of metrics to measure the effectiveness of the Pharmacy Quality Program. Documents situations and resolutions in the records (“logs”).
ADDITIONAL FUNCTIONS :
MINIMUM QUALIFICATIONS :
Education and Experience : Associate Degree in Pharmacy Technician. At least three (3) years of experience in Pharmacy practice, Healthcare Insurance industry, or in PBM (Pharmacy Benefit Management) or related areas.
Certifications / Licenses : Pharmacy Technician License and Registration is required. A Driver's License valid in the Commonwealth of Puerto Rico is required.
Other : A car in good condition and available to move to different Puerto Rico locations. Advanced knowledge in Microsoft Excel, including Pivot Tables, VLOOKUP’s, Tables, Graphs, Filters, and Formulas. Knowledge of pharmacy claims processing platforms and clinical programs preferably.
Languages :
Spanish – Advanced (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)
Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento”
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Insurance
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