Manager Pharmacy Quality and Contract Oversight - Presbyterian Healthcare Services

Overview:

Now hiring a Manager Pharmacy Quality & Contract Oversight!

Responsible for coordinating internal and external pharmacy audits and direct oversight of sub-contracted Pharmacy Benefit Manager (PBM) for delegated and non-delegated functions. Ensures PBM and Pharmacy operations comply with client agreements, applicable state and federal regulations, laws and National Committee of Quality Assurance (NCQA) accreditation programs. Ensures that services to members with pharmacy benefits are delivered in accordance with client contracts and applicable state and federal regulations, laws and accreditation programs. 

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

• Full Time - Exempt: Yes
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

Ideal Candidate:

Five+ years experience in the pharmacy department of a Health Plan or PBM or equivalent experience in auditing/compliance/ health care.

 

Qualifications:

• Bachelors degree required
• Requires detailed coordination, organizational and project management skills.
• Experience in process improvement methodologies.
• Must be able to work cooperatively with other employees and departments and function effectively under pressure.
• Familiarity with Windows and Microsoft Office products. Supervisory experience preferred.

 

 

 

Responsibilities:

• Develop and maintain PBM Oversight Program to ensure compliance with policies, contractual obligations, compliance program and regulatory requirements. Activities include ongoing monitoring, auditing, reporting, data analysis, issue resolution, corrective action and relationship management and ongoing communication with PBM. Maintain records of oversight.
• Develop schedule and coordinate resources for internal monitoring and audits of pharmacy operations and PBM services. Coordinate resources and audit responses to external regulatory agencies and accreditation bodies. Maintain records of monitoring and audits. Conduct and/or participate in mock audits as needed for pharmacy related processes and actively prepare/participate in CMS/DHS/NCQA audits.
• *Develop schedule and maintain pharmacy policies to ensure compliance with business requirements, client agreements and applicable Federal and State regulations and accreditation standards.
• Develop/approve corrective actions plans (CAPs) as needed, to include specific areas of improvement, assigned accountability, and timelines. Maintain records of CAPs.
• Serve as a point of contact for pharmacy PBM sub-contracted services and report audit findings, present corrective action plans, and report progress to appropriate departments/personnel.
• Serve as a liaison between Pharmacy Services, client and PBM sub-contractor to ensure timely reporting, acknowledgement and resolution of complaints / grievances and suspected fraud and abuse cases which are reported directly to the sub-contractor.
• Perform other functions as required.

Benefits:

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

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Maximum Offer for this position is up to:USD $59.41Compensation Disclaimer:The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.