Creating and maintaining pharmacy policies and procedures ensuring compliance with state, CMS and NCQA guidelines for Medicare Part D, Commercial, WV Medicaid and Self-Funded lines of business. Monitor timeliness for Part D and Part B prior authorizations and complete reporting with results, identifying trends and assisting with retraining when required. Monitor PDE rejection reports working client assigned rejections to completion.Complete and submit response forms for PDE analysis and CMS Timeliness Audit.Monitor pharmacy claims rejections for transition through report validation.Maintain, gather and organize necessary documents for NCQA accreditation submission for Utilization Management, Pharmacy Management and Member Experience as they apply to pharmacy services. Identifies, monitors and tracks vendor compliance with all contractual commitments within existing vendor agreements by validating reports, performing quality checks, and reviewing PBM policies and procedures. Identifies, monitors and tracks vendor compliance with all contractual commitments within existing vendor agreements by validating reports, performing quality checks, and reviewing PBM policies and procedures. Review and validate adjustment reports received from PBM.Work with PBM to ensure compliance of pharmacy member and provider materials. Complete and validate yearly CMS Part D reporting.Assist with development and implementation of quality management program and evaluation.Work with clinical pharmacist for CMS audits and serve as the driver during the audit.

Responsible for day-to-day operations of pharmacy call center by ensuring quality and compliant outcomes for member and providers.Manage pharmacy technicians including job description creation, hiring, training, payroll, coaching and evaluations. Oversee appeals and grievances for Medicare Part D, commercial and self-funded lines of business. Ensure quality and compliance of pharmacy services call center.Creating and maintaining pharmacy policies and procedures ensuring compliance with state, CMS and NCQA guidelines for Medicare Part D, Commercial, WV Medicaid and Self-Funded lines of business. Complete and submit response forms for PDE analysis and CMS Timeliness Audit.Assist clinical pharmacist with CMS program audits and serve as the driver during the audit.Work with PBM to ensure yearly Part D materials are compliant.Ensure quality and success of pharmacy services call center through oversight of reporting and review of call documentations.Validate and submit yearly CMS Part D reporting.Assist with development and implementation of quality management program and evaluation.Gather and submit necessary data for pharmacy class actions. Assemble pharmacy department documentation for CMS audits.Assist clinical pharmacist with CMS program audits and serve as the driver during the audit.

Maintain, gather and organize necessary documents for NCQA accreditation submission for Utilization Management, Pharmacy Management and Member Experience as they apply to pharmacy services. Assist with development and implementation of quality management program and evaluation.Gather and submit necessary data for pharmacy class actions. Maintain accuracy of two formularies on Epocrates site.Assemble pharmacy department documentation for CMS audits.Complete and upload response forms for PDE analysis and CMS Timeliness Audit.Assist clinical pharmacist with CMS program audits and serve as the driver during the audit. Maintain policies and procedures for operations of Pharmacy Services ensuring they meet CMS and NCQA standards.Work with PBM to ensure yearly Part D materials are compliant.Ensure quality and success of pharmacy services call center through oversight of reporting and review of call documentations.Complete and validate yearly CMS Part D reporting.

Provide member support with pharmacy benefit questions regarding Medicare, commercial and self-funded lines of business through an automated call distribution system.Assist providers with prior authorization requests via Express Scripts software.Assist pharmacies with claim rejections through Express Scripts software.

Manage calendar for the Director of Pharmacy ServicesCompile data and submit pharmacy class actionsScan documents to member foldersPrepare senior staff reportsAssist Pharmacy Operations Manager with compiling data for NCQA submission.