|
HealthPartners is currently hiring a Pharmacy UM Quality Specialist This position supports quality of the overall product for the prior authorization program, including utilization management/utilization review. This role is focused on conforming to regulatory and accreditation standards specific to pharmacy utilization management (UM) reviews. The position provides timely and effective feedback and ensures quality of departmental prior authorization reviews via case auditing. Risk management and mitigation and quality monitoring are primary accountabilities. MINIMUM QUALIFICATIONS:
| Education, Experience or Equivalent Combination: |
Bachelor's Degree or equivalent experience Three years' experience in managed care pharmacy, program compliance, utilization review and utilization management |
| |
|
| Knowledge, Skills, and Abilities: |
General understanding of all types of UM reviews for pharmacy prior authorization Demonstrated comprehensive, in-depth knowledge, of corporate compliance requirements Expertise in working collaboratively and communicating with staff in different positions and all levels of management positions High degree of initiative and ability to work independently and within a group Excellent written and oral communication skills Excellent computer skills including Microsoft Word, Outlook, Power Point and Excel Excellent technical and business writing and editing skills with a focus on policy and procedure writing Effective work history with range of internal and external customers Excellent follow through, problem-solving skills and attention to detail Ability to work independently and as part of a team |
PREFERRED QUALIFICATIONS:
| Education, Experience or Equivalent Combination: |
Previous experience in HealthPartners Pharmacy Administration and pharmacy UM reviews Direct work experience with government programs and regulatory matters Experience working with a utilization software program Minimum two years compliance background |
| |
|
| Knowledge, Skills, and Abilities: |
Knowledge of HealthPartners systems and applications |
| Essential Duties: |
% Of Time |
|
| 1. |
Quality Monitoring for Utilization Management Program Maintains a thorough and comprehensive understanding of department processes and expectations to promote consistency, ensure adherence to, and maintain quality standards Understands process changes within the department that impacts case processing, workflow, letters, and monitors for adherence with changes Supports accuracy of data used to monitor adherence to turnaround times, letter standards, and notification standards Support regulatory compliance by routinely reviewing coverage determination audit requirements Develops and executes monitoring and compliance activities with project management tools and approaches Communicates progress of monitoring program and issues for resolution to leadership team |
50% |
| 2. |
Audit/Compliance and Reporting Monitors audit reports daily, weekly, and monthly for tracking and trending issues or risks Utilizes audit tools, to ensure compliance with Federal and State review regulations, performance standards and audit readiness are met |
25% |
| 3. |
Support Functions for Staff Training Works closely with the other pharmacy staff to assure that training, procedures, task lists and quality standards are met |
10% |
| 4. |
Pharmacy Utilization Management Systems Support Actively participates in system updates and testing of application and process changes, as needed |
10% |
| 5. |
General Performance/Knowledge Maintains appropriate confidentiality of information in accordance with HealthPartners corporate policies Develops and maintains positive, effective working relationships with prior authorization program review and support staff Demonstrates responsiveness to and appreciation of constructive feedback and recommendations for personal growth and development Performs other duties, as assigned |
5% (these are overarching duties incorporated in all daily work) |
*Job description rankings/percentages are intended to reflect normal averages over an extended period of time, and are subject to daily variances. Quality and efficiency standards should at no time be compromised to meet the average expectations expressed above. Job descriptions are subject to change to accommodate organization or department needs. DECISION-MAKING: (What rules or precedents limit the activities and authority of this position? What types of problems or decisions are referred to the supervisor?) Review of utilization review and utilization management cases against regulatory and contractual compliance, performance, and quality standards Clear and concise communication with staff in a range of different positions Appropriate notification to leadership team of regulatory trends and immediate issues ORGANIZATIONAL EXPECTATIONS: Values All colleagues are expected to live our values: Excellence: We strive for the best results and always look for ways to improve. Compassion: We care and show empathy and respect for each person. Partnership: We are strongest when we work together and with those we serve. Integrity: We are open and honest, and we keep our commitments. Additional Expectations: Complies with safety instructions, observe safe work practices, provides input on safety issues, and promotes a safe work environment. Maintains regular and timely attendance Protects confidentiality Demonstrates participation in and support of the organization's Corporate Integrity Program by participating in compliance-related education and training and complying with the organization's policies and procedures. Timely completion of all mandatory education and organizational requirements (i.e., licensure/certification, Employee Health and Wellness requirements, annual training, etc.)
|
HealthPartners
Dec 23, 2024