Medicare Part D Service Rep

Req# 13719

Aultman Health Foundation, CANTON, OH

AULTCARE ADMINISTRATION

Aultman Health Foundation

Full Time, Day Shift, 8am - 4:30pm

The primary function of the Medicare Part D Representative is to perform ongoing coordination and resolution of service issues, claims processing, coverage determinations and analysis of the pharmacy benefit plans for all Primetime Health Plan clients. The Medicare Part D Representative will be cross-trained to handle issues regarding the use and maintenance of the Part D pharmacy benefit. This position must consistently relay the positive aspects of PTHP to every caller, internally and externally. The representative is responsible for accurately, courteously, and promptly transacting all requests in a highly professional manner in compliance with CMS and NCQA standards at all times.

This position requires a hands-on approach to the review, analysis, and comprehension of current and new requirements as published by CMS. The Part D Representative is responsible for meeting or exceeding turnaround time standards and quality expectations of Medicare Part D as put forth by CMS. The person must work effectively cross- functionally to address internal and client/beneficiary inquires/issues. Ability to understand process flows. The Medicare Part D Representative will assist the Medicare Part D team in projects that are assigned on an ad-hoc basis. 

·        Answers incoming calls, emails, and other requests.

·        Build and maintain knowledge of Medicare part D group prescription benefit designs.

·        Provides follow up on claim, benefit, and eligibility inquiries regarding prescription benefits.

·        Serve as a liaison between PTHP internal departments, pharmacies, and pharmacy management companies.

·        Research and follow up on drug pricing reviews.

·        Maintain drug status change tracking and quality assurance checks for formulary development

·        Ensure daily operations of pharmacy benefits.

·        Knowledge of Mail Order Program/Vendor.

·        Knowledge of CMS guidelines to Part D and quality metrics.

·        Accurately report and document pertinent information.

·        Use good judgment in referring inquires to other peers, supervisor, and Pharmacy Director.

·        Consistently demonstrate ability to multi-task and prioritize work in accordance with organizational position and necessity.

·        Accurately check eligibility of member and obtain information when necessary.

·        Interpret and apply plan language correctly.

·        Conform to any legal mandates related to the plan, such as, but not limited to: appeal rights and the external review process.

·        Adhere to notification guidelines related to healthcare requests

·        Accurately track turnaround times for designated tasks.

·        Maintain accurate and complete documentation in electronic data systems.

·        Process Improvement: Continuously reviews, recommends and implements improvement steps, as needed or directed.

·        Seeks supervisory guidance/approval as appropriate.

·        Portrays professional image: follows dress code; communicates with internal and external customers in a professional manner, including appropriate verbal and written grammar.

·        Promotes and demonstrates professional standards to enhance the development of the department.

·        Practices ethical conduct

·        Meets acceptable attendance and punctuality expectations (excluding FMLA)

The above statements reflect the general duties considered necessary to describe the principle functions of the job as identified, and is not a detailed description of all the work requirements that may be inherent to this position.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, age, national origin, disability, or protected veteran status. AultCare is an EEO/AA Employer M/F/Disability/Vet.

·        Education: High school diploma or GED required

·        Medicare Part D experience preferred

·        CPhT or Pharmacy experience a plus but not required

·        Knowledge of Microsoft Office Suite (Word, Excel, Outlook, etc.)

·        Day shift, of which an eight-hour shift or flex schedule as assigned. Occasional overtime. On-call hours are required, off-shifts (evenings and/or weekends) scheduled as necessary.

·        Lunch and break periods must be coordinated with other staff members to maintain adequate office staffing during departmental operating hours.

·        Frequent sitting, use of hands/fingers across keyboard or mouse, and long periods working at a computer.

·        Occasionally walking, standing, twisting/turning and reaching upward or forward during work day.