Job Details

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary

The Pharmacy Quality Advisor will support focused efforts and initiatives to drive improvement for our Medicare beneficiaries. These efforts will be focused on Pharmacy related to HEDIS and CMS Star measures. The specialist will conduct member outreach, monitor adherence data, and coordinate with internal and external partners to support quality improvement initiatives.

This role will also collaborate closely with pharmacists, providers, and care management teams to improve patient outcomes, reduce hospitalizations, and enhance quality performance measures.

Job Description

PRIMARY DUTIES AND RESPONSIBILITIES

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

• Performs routine audits of pharmacy operations, prior authorization requests, and appeals processes to ensure accuracy and compliance with federal, state, and accreditation regulations (e.g., NCQA).

• Adheres to HIPAA, DoD, CMS, and all state, federal, departmental, and organizational policies to ensure patient privacy and compliance.

• Analyzes claims and utilization data to monitor performance metrics and track key quality indicators (e.g., HEDIS, Medicare Stars measures).

• Conducts strategic outreach to members to identify barriers to adherence and assist with resolution.

• Tracks, trends, presents and reports common adherence barriers and member feedback to inform quality improvement efforts to health plan leaders (for example, quality and CM) and delivery system

• Leads quality improvement projects and initiatives using data analysis and root cause analysis to identify and resolve process problems and enhance efficiency and quality.

• Partners with clinical leaders of the health plan and delivery system to develop, implement, and execute effective medication adherence initiatives and other quality improvement efforts.

• Develops and maintain standard operating procedures (SOPs), work instructions, and training materials.

• Develops and manage library of pharmacy related materials.

• Serves as a liaison between providers, pharmacists, patients, and community pharmacies.

• Collaborates with cross-functional teams (clinical, IT, operations) on quality measures, health plan performance, and alignment of clinical and operational goals.

• Serves as a resource for formulary, prior authorizations, and cost-sharing inquiries.

POSITION QUALIFICATIONS

There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

Education

• High school diploma or equivalent required.

• Associate's or bachelor's degree in healthcare-related field preferred.

• Certified Pharmacy Technician (CPhT), Medical Assistant, or similar clinical experience preferred

Experience

• 2+ years' experience in operations, data analysis, or program development related to health care

• 2+ years' experience Managed Care, Health Plan, and Part D benefits/program experience

• Prior experience or exposure to pharmacy or managed care pharmacy preferred

• Experience in quality management or compliance roles strongly preferred

Knowledge

• Knowledge of Medicare Part D regulations, health plan operations, Pharmacy Benefit Management operations, and best practices preferred

• Knowledge of pharmacy operations, medications, and chronic disease management

• Experience with Medicare Star Ratings and knowledge of adherence-related measures preferred.

Skills

• Windows Based Computer skills: data entry and word processing ability

• Working knowledge of Microsoft Office products including Word, Excel and PowerPoint

• Demonstrated telephone etiquette and positive interpersonal skills

• Strong communication, empathy, and problem-solving skills

Abilities

• Strong interpersonal skills and ability to collaborate with internal and external clients

• Excellent customer services skills

• Superior written and verbal communication skills

• Ability to be flexible with changing priorities and work in a fast-paced environment

• Applies proactive and innovative solutions to improve process effectiveness when appropriate

• Solid analytical skills

• Ability to reconcile financial reports and data

• Strong mathematical ability

• Knowledge of PBM third party billing, pharmacy claims processing, and pharmacy data management

• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint)

• Strong organizational skills

• Self-motivated with ability to manage, prioritize and complete multiple projects in a timely fashion with limited supervision

• Takes appropriate initiative while soliciting input/advice

• Ability to handle confidential and sensitive information in a discreet and professional manner

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact ...@martinspoint.org

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