Pharmacy Program Specialist - Spanish/English Bilingual

At Clover Health, we are committed to providing high-quality, affordable, and easy-to-understand healthcare plans for America’s seniors. We prioritize preventive care while leveraging data and technology through the Clover Assistant, a powerful tool that helps physicians make informed health recommendations. By giving doctors a holistic view of each member’s complete health history, we ensure better care at a lower cost—delivering the highest value to those who need it most.

The Clinical Pharmacy team is an innovative team that utilizes a member-centric approach to provide comprehensive medication management services. The Pharmacy Programs Specialist will work to support Medicare quality metrics, medication management initiatives, and maintain Centers for Medicare and Medicaid Services compliance standards.

In this role, you would perform validation of claim adjudication ensuring appropriate access to care and support telephonic outreach for plan members, providers and other healthcare professionals. In addition, document activity and maintain electronic medical records while providing the highest quality healthcare and service to plan members and other internal and external partners.

As a Pharmacy Programs Specialist you will:

• Create, manage, and respond to cases and/or escalate to Clinical Pharmacists on the Team.
• Contribute to improving Part D Star measures by resolving root causes of medication management problems and taking appropriate action to provide recommendations based on profile review or patient interview.
• Represent for the Pharmacy team and participate in cross-functional team meetings
• Collect and present data and trends from Pharmacy Benefits Manager (PBM) delegated functions to cross-functional operational workgroups to propose process improvements
• Deliver on cross-functional team initiatives and ad-hoc projects that impact Clover business goals
• Provide guidance to internal and external teams in regards to pharmacy clinical and regulatory workflows, policies and processes
• Serve as a liaison between PBM Account Management Team and Clover Health and escalate any questions that need PBM involvement for resolution.
• Organize pharmacy team meetings with internal and external partners.
• Think critically and problem solve to prioritize and work more efficiently
• Improve team’s capacity and knowledge
• Distribute work to peers and strategize completion of quality assurance projects that require short turn around times 
• Provide recommendations on and deliver Part D content knowledge updates on internal knowledge base directory annually and ad-hoc 
• Lead educational training for cross functional teams on Part D knowledge and vendor platforms
• Participate in call center quality assurance reviews 
• Perform strategic work to increase MTMP Star measure
• Navigate and use tools and platforms required for task/queue-based work
• Show curiosity as to how work impacts the business and how that work is generated
• Complete a larger volume of assigned tasks with increasing focus on program/project-based opportunities and work and serve as a resource to others
• Communicate with the pharmacy leadership team in a timely manner when issues arise.
• File, review, and validate reports to ensure compliance with Medicare guidelines.
• Gather data and generate reports to improve clinical pharmacy quality metrics.
• Participate in training and orientation of new team members, as needed.
• Execute other job duties as assigned.

Success in this role looks like:

• Within 90 days: You have seamlessly integrated into the Pharmacy team and completed all the necessary training modules, familiarize yourself with the organization's platforms, and established a strong knowledge of Clover Health Part D benefit. You are capable of validating claim adjudication to ensure appropriate access to care and provide telephone support to plan members, prescribers, and pharmacies.
• Within 6 months: You will be fully engaged in oversight of accurate Part D benefits that are in compliance with CMS requirements. You have demonstrated the ability to collaborate effectively with interdisciplinary teams, providing member experience support and contributing to resolving member medication related escalations.
• Long-term: You will be measured based on pharmacy operational metrics, the integration of innovative technologies to enhance pharmacy services and improve patient outcomes, the enhancement of operational efficiency, and contributions to achieving the organization’s strategic objectives and key results.

You should get in touch if:

• You have a National Certification (CPhT)