Job Description

MetroPlus Health provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus Health 's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 40 years, MetroPlus Health has been committed to building strong relationships with its members and providers.

Position Overview:

The Pharmacy Intern II is responsible for auditing and validating internal and external reports to ensure proper benefit configuration across all lines of business. The Pharmacy Intern II will also assist in all other Pharmacy department directives. Additionally, the Pharmacy Intern II is responsible for assisting the Clinical Pharmacy Manager with all aspects of formulary management, care management and utilization management strategies across all lines of business. The Pharmacy Intern II will be responsible for improving patient care through various clinical programs, medication reconciliation, counseling and care management in the form of rotations. This resident will have opportunities to develop evidence-based clinical decision making, project management, analytic and leadership skills.

Work Shifts

9:00AM-5:00PM

Duties & Responsibilities

• Reviews daily claims reports of varying focuses across all lines of business to identify and report on the accuracy of the pharmacy benefit configuration.
• Review daily rejection reports to identify and report on inconsistencies or concerns that may impact patient care.
• Validates improper coding through verification between POS and UM platform systems.
• Coordinates care between members, pharmacies, and providers to improve patient adherence for chronic medications and to promote other pharmacy initiatives including assisting with pharmacy case management activities.
• Review daily reports to ensure all overrides are inputted correctly and claim adjudication is as intended.
• Assists in preparing documentation for internal and external audits and regulatory submissions.
• Reaches out to members, pharmacies, and prescribers to reconcile benefit inconsistencies.
• Reviews external communications for accuracy and appropriateness.
• Assists with prior authorization requests including inputting, providing notification for and reviewing needed.
• Complete core and elective rotations
• Assists with formulary and utilization management for medications across all lines of business.
• Develop drug monographs and coverage criteria upon request.
• Completes retro utilization review for drugs of interest and provides in depth analysis.
• Develops and maintains various pharmacy quality initiatives and generates regular monthly reports for key performance indicators.
• Provides education to staff on new therapies, new criteria, new guidelines to ensure internal pharmacy staff are versed on up-to-date trends.
• Assists in Pharmacy case management programs to improve quality of care and monitoring of MetroPlusHealth members.
• Assists in organizational and departmental quality improvement initiatives

Minimum Qualifications

• Doctor of Pharmacy required.
• Pharmacy experience in a managed care environment is preferred.
• Experience in auditing preferred.
• Experience in Pharmacy management of government programs (Medicaid and Exchange) preferred.
• Position requires excellent organizational, teamwork, interpersonal, time management, written and verbal communication skills.
• Proficiency with MS Word, Excel, and PowerPoint is required. Experience in the evaluation and interpretation of pharmacy claims data and other clinical data is preferred.
• Position requires excellent organizational, teamwork, interpersonal, time management, written and verbal communication skills

Licensure and/or Certification Required:

• Eligible for licensure in the state of New York (active and not limited Pharmacy Intern License plus Doctor of Pharmacy Degree).
• Licensure in the state of New York must be obtained within 90 days of start date.

Professional Competencies:

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Position requires excellent organizational, teamwork, interpersonal, time management, written, and verbal communication skills

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Job Tags

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