Description
Program Integrity Pharmacist
Position Description:
This position is responsible to serve in the Pharmacy Unit to review prescription claim patterns for potential irregularities. Based on their findings they will perform audits and make recommendations to the department for potential recoupment, claims adjustment, and prospective editing; and to support the Pharmacy Director in the management of the OHCA pharmacy programs.
PRINCIPLE ACTIVITIES:
* Analyzes pharmacy program and recommends interventions for cost-effective use of resources.
* Analyzes claims utilization for clinical issues using MMIS, Business Objects, and Excel.
* Systematically review claims patterns to certify that filled prescriptions are paid for appropriate participants, by appropriate prescribers, according to appropriate rates in accordance with State and Federal rules and regulations.
* Supports and assists Pharmacy Director with policy development through reporting and analysis, budget planning, rule drafting, and State Plan amendments.
* Supports and assists Pharmacy Director with MMIS claims processing enhancements such as new edits or audits.
* Directs and monitors pharmacy program contractor activities and assists in contract language, negotiation with contractor representatives, appropriations process, agency contracting process, and invoice reconciliation for all vendor contracted activities affecting the pharmacy department. These programs include, but are not limited to: State Maximum Allowable Cost, Prior Authorizations, and Drug Utilization Review.
* Run, review, and make recommendations on data for financial reports to minimize waste, fraud and abuse.
* Assist providers with claim issues to minimize waste, fraud and abuse.
* Run monthly reports and review claims over $1000 for potential billing errors.
* Consults with provider pharmacists and physicians related to the pharmacy program.
* Respond to provider/recipient inquiries via written, verbal, or electronic means.
* Represents OHCA regarding pharmacy issues with external stakeholders and at various meetings.
* Other duties as assigned.
TRAVEL: Travel on an "as needed" basis.
Accommodation Statement:
The Oklahoma Health Care Authority complies with applicable Federal civil rights laws and does not discriminate. All qualified applicants will receive consideration for employment without regard to race, color, sex, religion, disability, age, national origin, or genetic information. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact the Civil Rights Coordinator at .
MINIMUM QUALIFICATIONS
KNOWLEDGE AND BACKGROUND REQUIREMENTS
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill, and/or ability required.
Skill in establishing and maintaining effective working relationships with pharmacists, physicians, hospital and nursing home administrators; recommending pharmacy improvements; analyzing and resolving pharmacy issues; and communicating with staff and external stakeholders. Understanding changes in the pharmaceutical industry and its impact on the health care delivery system as well as knowledge in budget planning and projection.
EDUCATION AND/OR EXPERIENCE:
* Bachelor of Pharmacy (R. Ph) or Doctor of Pharmacy (Phar.D.) degree AND
* Currently licensed as Doctor of Pharmacy in the State of Oklahoma AND
* Seven (7) years of Pharmacy experience; OR
* an equivalent combination of education and/or experience totaling 11 years.
PREFERENCE MAY BE GIVEN TO CANDIDATES WITH:
* Experience with claims analysis for health plans, pharmacy benefit management, or drug utilization review
* Medicaid experience (especially SoonerCare)
NOTES
Please read instructions carefully and include all required documents when you submit your application.
No additional information will be accepted after the application has been submitted.
