As one of the nation’s largest not-for-profit Medicare Advantage plans, serving more than 200,000 members in California, SCAN Health Plan has been a mission-driven organization dedicated to keeping seniors healthy and independent for over 40 years. SCAN employees are passionate about what they do, and understand that success is based on achieving the mission. Employees are afforded with the training and tools necessary to do their jobs and are rewarded for their efforts and recognized as experts in their fields. To learn more, visit scanhealthplan.comor follow us on social media:LinkedIn; Facebook; andTwitter.
Oversee the daily functions and responsibilities of the Pharmacy Benefits Administrators (PBAs) to include ensuring that the pharmacy benefits, formulary, pharmacy network provided to members are set up accurately with the PBM (Pharmacy Benefit Manager). Coordinate assistance with formulary and benefits analyses; provide oversight of the delegated functions of formulary and benefits implementation by the PBM; assign PBAs to participate in a variety of work projects; and be responsible for accurate and timely completion of different projects as assigned.
Ensure regulatory compliance prescription benefits/formulary/transition policy setup and year-round CMS Program Audit readiness in the area of formulary and benefits administration.
Oversee the correct implementation and maintenance of SCAN’s pharmacy network, including GEO access requirements.
Ensure accuracy and completeness of the member pharmacy-related communication marketing materials.
Oversee accuracy of the pharmacy content on the SCAN website and Medicare.gov website.
Ensure Annual Enrollment Period (AEP) readiness and assist in training of other departments on Pharmacy programs and information.
Review and ensure accuracy of the Pharmacy Benefits for the annual BID submission to CMS.
Provide support during CMS Regulatory Audits; e.g., ensure accuracy of written responses and/or documentation for the pharmacy audits.
Supervise and coordinate day-to-day operations of the Pharmacy Benefits Administrators (PBAs). Plan and assign workflow and project assignments for staff.
Resolve issues and monitor results of daily staff activities, keeping management informed of key issues and problems as encountered.
Ensure accurate benefits/formulary/transition/pharmacy network setup for all business lines via the following mechanisms:
Daily paid and rejected claims report oversight, including transition claims and B vs. D rejected claims
Claims adjudication testing oversight
Member Transition Letter TAT report oversight
Prescriber Transition Notification oversight
Pharmacy Network Files and Pharmacy Access Requirements oversight
Prompt benefits error reporting to, and resolution with, the PBM.
Ensure CMS formulary compliance, e.g., oversight of timely and accurate formulary submissions to CMS with subsequent implementation of approved changes in the PBM adjudication system.
Prepare benefits/formulary analysis reports of other Medicare Part D Plans vs. SCAN to ensure SCAN’s pharmacy benefits and formulary meet the industry standard.
Oversee testing of benefit changes for the upcoming year. Serve as Pharmacy Benefits Expert to the Pharmacy team and other departments.
Develop, implement, and maintain department’s standard operating procedures to ensure ongoing compliance.
Coach and mentor Pharmacy Benefits Administrators.
Maintain staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; and developing personal growth opportunities.
Instill a culture of continuous process improvement, efficiency, collaboration, operational excellence and compliance amongst team.
Maintain strong rapport with PBM representatives such that team’s goals and needs are met.
Oversee PBM operations to ensure high-service level to SCAN and our members.
Maintain current knowledge of Medicare Part D regulations by participating in CMS calls, reading released guidance and implementing changes to maintain compliance.
Foster strong relationships with internal departments and external providers.
Contributes to team effort by accomplishing related results as needed.
Actively supports the achievement of SCAN’s Mission and Organizational Goals.
High School Diploma or G.E.D required.
Bachelor's Degree preferred.
Active Pharmacy Technician License preferred.
5+ years of experience in managed care pharmacy department operations required.
3+ years' of supervisory or similar leadership experience preferred.
3+ years' of Medicare Part D experience with a health plan or PBM including formulary and benefits management preferred.
3+ years' experience in data analysis preferred.
Ability to research, analyze and resolve pharmacy benefit issues independently.
Ability to take the lead on projects and see them through to completion.
Strong interpersonal skills, including excellent written and verbal communication skills.
Strong organizational skills; Ability to multitask.
Ability to appropriately maintain confidentiality.
Strong analytical and critical thinking skills.
What's in it for you?
A competitive compensation and benefits program
An annual employee bonus program
Generous paid-time-off (PTO)
Ten paid holidays per year
Excellent 403(b) Saving Plan, providing up to 4 % match and vesting after three years
A Work - life balance and much more!
At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.
SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employee will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
Internal Number: SUPER03614
About SCAN Health Plan
As one of the nation’s largest not-for-profit Medicare Advantage plans, serving more than 200,000 members in California, SCAN Health Plan has been a mission-driven organization dedicated to keeping seniors healthy and independent for over 40 years. SCAN employees are passionate about what they do, and understand that success is based on achieving the mission. Employees are afforded with the training and tools necessary to do their jobs and are rewarded for their efforts and recognized as experts in their fields. To learn more, visit scanhealthplan.com or follow us on social media: LinkedIn; Facebook; and Twitter.