This position specializes in the analyzing and solving intermediate level of benefit design requirements. This role requires strong attention to detail, extensive pharmacy benefits administration knowledge, and well-honed analytical skills to assist both internal and external stakeholders in implementing and maintaining plan benefits. This position plays a critical role in the formulary administration, benefit programing, implementation, mapping, audit protocols, and validation process. The Plan Administration team as a whole is responsible for the plan benefit management and coding of multiple lines of business (Commercial, Medicaid, Medicare, Affordable Care Act Exchange, and Managed Care) across a number of different adjudication platforms. This position will ensure a high level of quality and accuracy through pharmacy benefit analysis, peer auditing, and strong relationship building with our internal Quality Assurance (QA) resources. Participates in new customer implementations.
- Analyzes new business requirements for benefit designs and changes in order to establish the appropriate solution for our internal and external stakeholders.
- Responsible for accurate administration of plan benefits coding changes, and new plan benefit designs into the appropriate adjudication system.
- Assists in ongoing development and improvement of audit process to include; peer testing solutions, and partnering with QA team resources.
- Maintains customer documentation which validates configuration.
- Maintains technical documentation based on standard operating procedures in support of the assigned clinical application.
- Interacts with Clinical and development team during the software build or configuration and testing process
- Establishes cross departmental relationships to ensure the success of all plan administration responsibilities.
- Leads, coordinates, or consults on intermediate level projects including new customer implementations, global projects spanning multiple clients or systems, and system implementations or enhancements.
- Efficient and effective distribution of tasks, using clear and concise instructions and expectations.
- Prepares updates and reports, including those required for either internal and SOX audits.
- Serves as primary contact for our internal and external customers regarding benefit plan configuration feasibility requests.
- Oversees configuration and testing of system enhancements.
- Partners with testing team to research any discrepancies identified with regression and release testing for system enhancements and/or benefit plans.
- Designs and executes unit, system and integration test plans for new developments/releases/reports.
- Provides support to internal partners responsible for developing, monitoring, improving operational controls related to formulary and benefit coding.
- Provides operational and maintenance support for assigned adjudication system and supporting tools (i.e., CRM, Formulary software).
- Demonstrates an understanding of end user business needs, and works closely with end users to identify problems and provide technical solutions.
- Other duties as assigned.
Other Job Requirements
- Ability to interpret and understand benefit requirement documents, and client intent.
- Ability to understand adjudication logic, and system compatibility to best optimize auto-adjudication processes. Ability to identify process and/or systems issues.
- Strong sense of urgency leading to the timely completion of all projects, training and assignments.
- Strong work ethic and focused attention to detail will be beneficial in ensuring success and professional advancement.
General Job Information
Pharmacy Benefit Plan Administrator I
Benefit Plan Administration, Claims, Formulary Management, Medicare Part D (MedD)
License and Certifications - Required
License and Certifications - Preferred
CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their
position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.