Compliance and Operations Pharmacy Utilization Management Analyst

HealthPartners is hiring a Pharmacy UM Compliance and Operations Analyst. This position works with pharmacy leaders to develop and implement monitoring tools that ensure compliance, performance standards and audit readiness. The position provides timely and effective feedback and ensures quality of departmental prior authorization and exception reviews via case auditing. This position ensures a collaborative and integrated approach to utilization management processes and quality. This position will also serve as a subject matter expert for pharmacy utilization management applications, including working as a liaison between the business and IT teams. This position provides support and coordination for the pharmacy utilization management team in maintaining a constant state of readiness for and compliance with regulatory and accreditation requirements.

 

MINIMUM QUALIFICATIONS:

Education, Experience or Equivalent Combination:

Bachelor's Degree or equivalent experience

Three years’ experience in managed care pharmacy, program compliance, utilization review and utilization management

Licensure/ Registration/ Certification: Knowledge, Skills, and Abilities:

Knowledge of quality standards and regulations

Demonstrated comprehensive, in-depth knowledge, of corporate compliance requirements

Ability to plan, organize, and prioritize work effectively, including the flexibility to accommodate frequent changes

Expertise in working collaboratively and communicating with staff in different positions and all levels of management positions

Strong analytical and problem-solving skills related to software system-based processes

Working knowledge of various reporting tools and strategies

Ability to deal with ambiguity and changing priorities

High degree of initiative and ability to work independently and within a group

Excellent written and oral communication skills, including facilitation and presentation skills in technical and non-technical vernacular

Excellent computer skills including Microsoft Word, Outlook, Power Point and Excel

Excellent technical and business writing and editing skills with a focus on policy and procedure writing

Effective work history with range of internal and external customers

Excellent follow through and problem-solving skills and attention to detail

Ability to work independently and as part of a team

 

PREFERRED QUALIFICATIONS:

Education, Experience or Equivalent Combination:

Previous experience in HealthPartners Pharmacy Administration and pharmacy UM reviews

Direct work experience with government programs and regulatory matters

Experience working with a utilization software program

Experience working with Compliance 360 monitoring tool 

Licensure/ Registration/ Certification: Knowledge, Skills, and Abilities:

Knowledge of HealthPartners

Knowledge of HealthPartners systems and applications

Experience with Microsoft Access

 

Essential Duties:% Of Time (minimum 5% increments)1.

Support Functions for Staff Training

Works closely with the other pharmacy staff to assure that training, procedures, task lists, and processes support policies, department needs, and regulatory and accreditation standards

Provides training and communication on program changes to staff as appropriate

Provide end user support and excellent customer service to pharmacy prior authorization staff in supporting and troubleshooting pharmacy utilization management software applications used by staff

Trains Pharmacy UM Quality Specialists as needed and assigned

Assist with training of Pharmacy Customer Service Assistants as needed and assigned

202.

Audit/Compliance and Reporting

Monitors audit reports daily, weekly, and monthly for tracking and trending issues or risks

Utilizes audit tools, to ensure compliance with Federal and State review regulations, performance standards and audit readiness are met

Support regulatory compliance by routinely reviewing all government programs utilization management reporting and audit requirements, NCQA standards, and applicable state regulations

Supports regulatory and accreditation audits including universe file pulls, file preparation, and submission of documentation as needed

Actively participate in audits and audit-related activities as required by NCQA, MDH, CMS, or other regulatory/accreditation agency

Identify and present opportunities for process improvement to increase data integrity, improve quality of reports, and ensure compliance

Advises the pharmacy prior authorization leadership team of potential compliance concerns

303.

Quality Monitoring for Uti