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Concurrent Review and Pharmacy Benefit Specialist
Category: Pharmacy
Job Type: Specialist
> More info about this job
Location: Tamuning, Guam
Job Summary:
Reports directly to Medical Management Supervisor and responsible for On-island and Off-island Concurrent Review and Pharmacy Benefit Management. Reviews treatment plans and services that are already underway, to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources. Evaluates the quality of care and its conformance with organizational policies, procedures, and guidelines, as well as compliance with government regulations. Responsible for the review of pharmacy utilization and the development and management of TakeCare Formulary, physician outreach protocols. Tracks physician prescribing patterns, interfaces with the Pharmacy Benefit Manager (PBM) and TakeCare members, external pharmacies as well as other pharmacy related entities. Reviews utilization and monitors costs, manages the activities of the PBM in adjudication of pharmacy claims and wrap-around network under the Plan. Supports TakeCare's PBM team to manage initiatives under the health plan.
Essential Duties and Responsibilities:
Concurrent Review:
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Review and analyze medical information either through telephonically or onsite, to determine the medical necessity of continued stay according to review standards. Also, in conducting further review and analysis to determine whether treatments are consistent with patients’ diagnosis.
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Determine medical necessity and length of stay based on the consistent application of decision support system, and communicates decisions to providers and patients.
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Initiate/coordinate discharge planning goals with physicians, members, families, caregivers and ancillary providers to support the member’s continuity of care needs.
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Provide customer/member support through benefit education to ensure accurate administration of member’s benefits and coverage.
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Identify day and cost outliers and prepares documents as well as provides reports on quality-of- care issues.
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Submit reports and communicates in a timely and effective manner to the Health Plan Administrator, Medical Director or designee, Medical Management Staff and other health team members.
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Perform onsite review of concurrent patient services and retrospective review of quality care issues, access and outcome studies.
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Determine and develop discharge plans and goals with providers and ensure implementation of identified discharge plan appropriately and timely.
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Maintain ongoing database/documentation to monitor all activities/treatment and outcome plans for patients’ conformance with organizational and government regulations.
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Conduct pre-contractual and other assessment surveys and a variety of quality management, utilization and claims audit.
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Ensure that services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized.
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Identify and refer catastrophically and chronically ill patients to case management when appropriate.
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Coordinate out of area and off-island in-patient cases ensuring patient receives cost-effective quality care and monitor patient for return to work or service area.
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Assists and support the Concurrent Review staff in performing the tasks assigned to him/her
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Performing other duties as assigned.
Pharmacy Benefit Management - Assists and support the Pharmacy Benefit Associate in:
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Acting as a coordinator with TakeCare's Pharmacy Benefit Manager to include but not limited to the following duties:
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Interfaces on all issues and solutions
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Manage reporting and disseminate reports and information
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Monitors transparency/payment issues
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Represent the Health Plan by participating in the Pharmacy and Therapeutics (P&T) team.
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Driving recommendations to execution and deliver cost savings for Health Plan and FHP Clinic
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Act as resource on pharmacy claims adjudication, drug pricing, or reimbursement for any on-island and off-island claim
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Closely working with the PBM to review all pharmacy utilization and tracks prescribing trends that lend themselves to improvement clinically and financially by utilizing pharmacy data to identify outliers and trends. Segments findings to identify high utilization by physician, clinic, and patient and develops reports to translate findings.
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Performing reviews and provides recommendations and/or approvals of drug therapies through a consistent application of guidelines aligning them with member's approved benefit plan and coverage.
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Compiling and reports on findings of utilization review and collaborates with the Medical Management Supervisor, Medical Director or Health Plan Administrator to develop solutions to segmented high utilization by physician, clinic, patient, drug, etc.
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Managing the implementation of solutions in collaboration with the Medical Management Supervisor, Medical Director or Health Plan Administrator that may include educational discussions, seminars, one-on-one discussions with physicians, use of patient educational materials, in designing and implementation of improvement methodologies.
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Engaging the network pharmacists/pharmacies on Guam to provide plan education and drive change management initiatives to ensure member satisfaction and streamlined communication.
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Interfacing with PBM’s Pharmacy and Therapeutic committee in the development and monitoring of TakeCare’s formulary by providing data on utilization, prescribing trends, and other related updates.
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Maintaining content responsibility of TakeCare’s formulary by addressing issues and initiating development of solutions and assumes formulary responsibility through proper and approval of new drugs, dissemination, update and management of TakeCare's formulary.
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Interfacing with other plan initiatives such as case and disease management to optimize pharmacy utilization and actively collaborate with disease management coordinator and case managers to develop effective program interventions that will optimize pharmacy resources and drug therapies
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Providing customer support through member education on formulary and plan benefits, prior authorization process, and coordinates with other network pharmacies to address customer concerns related to pharmacy benefit administration.
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Assisting with member open enrollment events by supporting the sales team effort to drive membership by educating new, renewing, and existing groups regarding our pharmacy benefit and the PBM programs we have in place.
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Performing other duties as assigned.
Education and Experience:
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Graduate of Bachelor’s Degree in any related medical field.
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Minimum of 2-year experience and must have impressive track record in reviewing treatment plans and services in order to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources; and pharmacy benefit management.
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Preferably a Nurse, LPN or a Pharmacy Tech.
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Prior medical and clinical pharmacy experience or background.
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Effective team player. With very good interpersonal relationship skills and can work and relate well with co-employees, patients and customers.
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Must have the behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and irate customers with outstanding oral and written communication skills.
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Strong ethics and a high level of personal and professional integrity.
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Must have basic familiarity on federal and state laws and requirements relating to healthcare management.
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Computer literate and very highly proficient in using MS office programs.
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TakeCare Insurance Company Inc.
More Info
For over 45 years, TakeCare Insurance Company, Inc. (NAIC No. 11093) (CAGE Code 563Z6) (DUNS 855034562) has been providing public and private employer groups, their employees, retirees, dependents and survivors comprehensive medical and dental insurance to its members in Guam, CNMI, Palau, and American Samoa. The breadth of TakeCare health plan offerings and culturally diverse staff provide its 30,000+ members with access to the largest health network in Micronesia with over 100 medical providers, 40 dental providers, and 20 pharmacies in the region.
TakeCare benefit plans also include access to an extensive off-island network of providers in Asia and the Pacific including Hawaii (medical, dental pharmacy), US Mainland (medical, pharmacy), the Philippines (medical, dental, pharmacy), as well as medical networks in Japan, South Korea, Singapore, Thailand, Taiwan, Australia, New Zealand and Malaysia. All of TakeCare’s network providers deliver a quality and a positive experience that ensures quality control of your health outcomes.
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February 07, 2025
08:00 AM ChST |
Open Until Position Is Filled |
OPEN |
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