InnovaCare Health
Pharmacy Quality Assurance Team Lead
It's fun to work in a company where people truly believe in what they're doing! We're committed to bringing passion and customer focus to the business. MMM of Florida, a proud member of the Innovacare Health family of companies, a powerful combination and the foundation upon which we're expanding. Innovacare Health is the 9th largest Medicare Advantage provider in the U.S. MMM of Florida is a licensed HMO, NCQA accredited, that serves individuals enrolled in Medicare Advantage plans. Join us, this is an exceptional opportunity to do innovative work for the benefit of those we serve. We currently have an opening for a Pharmacy Quality Assurance Team Lead. This position is responsible for assuring the quality and conformance of Pharmacy Operations to Centers for Medicare and Medicaid Services (CMS) and The Accreditation Association for Ambulatory Health Care (AAAHC). Evaluating current policies and procedures against CMS requirements to identify gaps and propose process improvements Assuring the compliance of system enhancements and implementations with required business needs Preparing and offering training to department staff on new CMS or AAAHC requirements, including exam administration as needed Performing monitoring and audits to internal and delegated pharmacy operations services and propose process improvements Executing all recovery efforts associated with Coordination of Benefits (COB), End Stage Renal Disease (ESRD), Hospice, Prescription Drug Events (PDEs), Low-Income Subsidies (LICs), and any other related processes Analyzing claim data in the adjudication system and utilization files in order to ensure quality controls are in place according to regulatory and business requirements Performing reconciliation of vendor invoices for the Pharmacy department Executing member and/or provider issue resolution of work basket cases Supporting CMS compliance in PDE management Includes executing and managing error resolution Supporting FIR and COB backend processes as well as any other reconciliation processes Executing monthly marketing materials quality processes for print and web versions Support and perform monthly audits and exam administration to pharmacy units Analyze and present recommendations to improve efficiency of systems/processes Assure the department stays abreast of and compliant with regulators' requirements, internal policies and procedures, and operationally efficient. Assess current policies and procedures against CMS requirements, identify gaps, and make improvements through: Internal monthly audits Monthly Exams to unit employees Delegated entities and vendor audits Perform Ongoing Compliance required Data Validation Audits Perform CMS Financial and Operations Audits Perform AAAHC yearly audits Generate and organize audit samples External monthly audits support/coordination Metrics monitoring Assure the coordination and management of the, at least, annual Policies and Procedures updates. Manage and update at least yearly and as applicable the Pharmacy Department training log and assure training needs are included in log and executed as agreed. Manage and coordinate as needed the Pharmacy Internal Audit Plan including but not limited to the following procedures: Medicare Plan Finder FIR/Nx Rejects Marketing Materials Troop PDE Rejects Monitoring MTM Program Coverage/Organizational Determinations Quality Process Formulary Administration Overutilization/Opioids P&T Committee Claims Processing Provider Call Center Recovery Process Create, update and manage the Pharmacy Corrective Action Plan/Workplans Log and manage through completion its execution according to established timelines. Create, Update and manage the Pharmacy Compliance Burning Issues Log and manage through completion its execution according to established timelines. Coordinate and lead the Pharmacy internal monthly compliance meeting. Perform other duties as designated by supervisor or Pharmacy Department head. Lead and coordinate quality and compliance tasks for the pharmacy positions. Support RxOps workbasket activities. Minimum Qualifications & Experience: Florida Board of Pharmacy Registered Pharmacy Technician and Certified Preferred. Bachelors' Degree or experience equivalent to 5 years in healthcare related job. Experience on query and report generation is a plus. Evidence of an advanced level of mathematical knowledge, and good communication, interpersonal, problem-solving, orientation to detail, and strive for excellence skills. Language Skills
Fully Bilingual (English and Spanish). Read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Write speeches and articles for publication that conform to prescribed style and format. Effectively present information to top management, public groups, and/or boards of directors. General Skills
Basic business intelligence knowledge and techniques Ability to complete thorough comparative analysis and conclusions. Object-oriented analysis. Computer knowledge. Familiar with basic concepts of project management and business analysis. Ability to respond to a high volume of work and always maintain a polite and professional manner. Must demonstrate positive attitude. Strong interpersonal skills. Able to function with frequent interruptions. Ability to prioritize workloads for maximum efficiency. Able to sit for extended periods of time without compromising work performance. Teamwork: ability to work in a team environment to provide solutions to problems Can work flexible schedules including night shifts, weekends, and holidays. Business modeling techniques Technical writing Mathematical Skills
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages. Ability to apply concepts of basic algebra, Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Reasoning Ability
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Physical and Mental Demands
Working on computer and telephone for long periods of time; ability to effectively utilize office telephone equipment; repetitive motion using fingers and forearms in data entry, manual dexterity to access filing system, use fax and copy machines. This position requires that weight be lifted, or force be exerted up to 10 pounds. Working Conditions: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Normal office environment. The noise is typically moderate. MMM of Florida is an equal opportunity employer. We are committed to providing a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the organization. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. We are dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment. If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
It's fun to work in a company where people truly believe in what they're doing! We're committed to bringing passion and customer focus to the business. MMM of Florida, a proud member of the Innovacare Health family of companies, a powerful combination and the foundation upon which we're expanding. Innovacare Health is the 9th largest Medicare Advantage provider in the U.S. MMM of Florida is a licensed HMO, NCQA accredited, that serves individuals enrolled in Medicare Advantage plans. Join us, this is an exceptional opportunity to do innovative work for the benefit of those we serve. We currently have an opening for a Pharmacy Quality Assurance Team Lead. This position is responsible for assuring the quality and conformance of Pharmacy Operations to Centers for Medicare and Medicaid Services (CMS) and The Accreditation Association for Ambulatory Health Care (AAAHC). Evaluating current policies and procedures against CMS requirements to identify gaps and propose process improvements Assuring the compliance of system enhancements and implementations with required business needs Preparing and offering training to department staff on new CMS or AAAHC requirements, including exam administration as needed Performing monitoring and audits to internal and delegated pharmacy operations services and propose process improvements Executing all recovery efforts associated with Coordination of Benefits (COB), End Stage Renal Disease (ESRD), Hospice, Prescription Drug Events (PDEs), Low-Income Subsidies (LICs), and any other related processes Analyzing claim data in the adjudication system and utilization files in order to ensure quality controls are in place according to regulatory and business requirements Performing reconciliation of vendor invoices for the Pharmacy department Executing member and/or provider issue resolution of work basket cases Supporting CMS compliance in PDE management Includes executing and managing error resolution Supporting FIR and COB backend processes as well as any other reconciliation processes Executing monthly marketing materials quality processes for print and web versions Support and perform monthly audits and exam administration to pharmacy units Analyze and present recommendations to improve efficiency of systems/processes Assure the department stays abreast of and compliant with regulators' requirements, internal policies and procedures, and operationally efficient. Assess current policies and procedures against CMS requirements, identify gaps, and make improvements through: Internal monthly audits Monthly Exams to unit employees Delegated entities and vendor audits Perform Ongoing Compliance required Data Validation Audits Perform CMS Financial and Operations Audits Perform AAAHC yearly audits Generate and organize audit samples External monthly audits support/coordination Metrics monitoring Assure the coordination and management of the, at least, annual Policies and Procedures updates. Manage and update at least yearly and as applicable the Pharmacy Department training log and assure training needs are included in log and executed as agreed. Manage and coordinate as needed the Pharmacy Internal Audit Plan including but not limited to the following procedures: Medicare Plan Finder FIR/Nx Rejects Marketing Materials Troop PDE Rejects Monitoring MTM Program Coverage/Organizational Determinations Quality Process Formulary Administration Overutilization/Opioids P&T Committee Claims Processing Provider Call Center Recovery Process Create, update and manage the Pharmacy Corrective Action Plan/Workplans Log and manage through completion its execution according to established timelines. Create, Update and manage the Pharmacy Compliance Burning Issues Log and manage through completion its execution according to established timelines. Coordinate and lead the Pharmacy internal monthly compliance meeting. Perform other duties as designated by supervisor or Pharmacy Department head. Lead and coordinate quality and compliance tasks for the pharmacy positions. Support RxOps workbasket activities. Minimum Qualifications & Experience: Florida Board of Pharmacy Registered Pharmacy Technician and Certified Preferred. Bachelors' Degree or experience equivalent to 5 years in healthcare related job. Experience on query and report generation is a plus. Evidence of an advanced level of mathematical knowledge, and good communication, interpersonal, problem-solving, orientation to detail, and strive for excellence skills. Language Skills
Fully Bilingual (English and Spanish). Read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Write speeches and articles for publication that conform to prescribed style and format. Effectively present information to top management, public groups, and/or boards of directors. General Skills
Basic business intelligence knowledge and techniques Ability to complete thorough comparative analysis and conclusions. Object-oriented analysis. Computer knowledge. Familiar with basic concepts of project management and business analysis. Ability to respond to a high volume of work and always maintain a polite and professional manner. Must demonstrate positive attitude. Strong interpersonal skills. Able to function with frequent interruptions. Ability to prioritize workloads for maximum efficiency. Able to sit for extended periods of time without compromising work performance. Teamwork: ability to work in a team environment to provide solutions to problems Can work flexible schedules including night shifts, weekends, and holidays. Business modeling techniques Technical writing Mathematical Skills
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages. Ability to apply concepts of basic algebra, Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Reasoning Ability
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Physical and Mental Demands
Working on computer and telephone for long periods of time; ability to effectively utilize office telephone equipment; repetitive motion using fingers and forearms in data entry, manual dexterity to access filing system, use fax and copy machines. This position requires that weight be lifted, or force be exerted up to 10 pounds. Working Conditions: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Normal office environment. The noise is typically moderate. MMM of Florida is an equal opportunity employer. We are committed to providing a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the organization. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. We are dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment. If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!