MCS Puerto Rico
Guarantees quality in implementing pharmacy benefits and forms and the medical component for all company business lines. Ensures that coding errors in the drug list on the Pharmacy Benefit Management (PBM) adjudication platform are corrected on time, that appropriate actions are taken to minimize the impact on insured parties, and that effective corrective measures are taken to prevent the recurrence of errors.
ESSENTIAL FUNCTIONS
Oversee the quality assurance of pharmacy benefits, formularies, and medical components across all company business lines, ensuring prompt identification and resolution of potential errors.
Report findings related to drug formularies and benefits to the PBM for timely corrections.
Ensure proper documentation of findings and their resolution to assess root cause and guarantee that appropriate corrective actions are implemented promptly in alignment with the established plan.
Validate the accuracy and completeness of impact reports and findings summaries.
Compile and assess potential findings related to drug formularies and benefits from various sources, providing timely resolutions in response to referrals.
Inform management of cases requiring changes in benefits and generate comprehensive reports highlighting metrics and trends of identified findings.
Escalate unresolved findings to management that do not align with the agreed-upon corrective action plan.
Assist in the preparation for audits conducted by regulatory agencies and support internal monitoring processes.
Analyze complex reports and deliver concise summaries to the management to facilitate informed decision‑making.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
Minimum Qualifications Education: Bachelor’s Degree in Natural Sciences, Pharmacy, or related field. At least three (3) years of clinical experience in Pharmacy, PBM, or the Healthcare Insurance industry.
OR
Education: Associate’s Degree in Pharmacy Technician. At least four (4) years of clinical experience in Pharmacy, PBM, or the Healthcare Insurance industry.
Proven experience may be replaced by previously established requirements.
Certifications / Licenses For an Associate’s Degree a valid Pharmacy Technician license and registration is required.
Other Requirements Advanced knowledge of Excel is required.
Languages Spanish – Advanced (written, verbal, comprehensive)
English – Intermediate (written, verbal, comprehensive)
Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento
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ESSENTIAL FUNCTIONS
Oversee the quality assurance of pharmacy benefits, formularies, and medical components across all company business lines, ensuring prompt identification and resolution of potential errors.
Report findings related to drug formularies and benefits to the PBM for timely corrections.
Ensure proper documentation of findings and their resolution to assess root cause and guarantee that appropriate corrective actions are implemented promptly in alignment with the established plan.
Validate the accuracy and completeness of impact reports and findings summaries.
Compile and assess potential findings related to drug formularies and benefits from various sources, providing timely resolutions in response to referrals.
Inform management of cases requiring changes in benefits and generate comprehensive reports highlighting metrics and trends of identified findings.
Escalate unresolved findings to management that do not align with the agreed-upon corrective action plan.
Assist in the preparation for audits conducted by regulatory agencies and support internal monitoring processes.
Analyze complex reports and deliver concise summaries to the management to facilitate informed decision‑making.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
Minimum Qualifications Education: Bachelor’s Degree in Natural Sciences, Pharmacy, or related field. At least three (3) years of clinical experience in Pharmacy, PBM, or the Healthcare Insurance industry.
OR
Education: Associate’s Degree in Pharmacy Technician. At least four (4) years of clinical experience in Pharmacy, PBM, or the Healthcare Insurance industry.
Proven experience may be replaced by previously established requirements.
Certifications / Licenses For an Associate’s Degree a valid Pharmacy Technician license and registration is required.
Other Requirements Advanced knowledge of Excel is required.
Languages Spanish – Advanced (written, verbal, comprehensive)
English – Intermediate (written, verbal, comprehensive)
Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento
#J-18808-Ljbffr