Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.
Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security. Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina. In addition, Clear Spring Health sponsors Medicare Prescription Drug plans in 42 states.
- Working with Pharmacy Team to ensure successful Adherence Outreach Program for members
- Reviewing and executing on P&P as it relates to Daily Claims rejection files to ensure that members are able to receive their medications timely
- Working on Clinical programs that include documenting cases on Case Management System around members that are in Drug Management Program, Medication Adherence Program, Statin Use in Persons with Diabetes, Obtaining information on Re-determination cases, assisting in scheduling members for MTM services, and additional clinical programs as needed.
- Assisting in part D grievances resolution
- Working with PBM and reviewing Call Logs, PDE errors, Eligibility errors, Explanation of Benefits file, Marketing Material for monthly maintenance, and other initiatives as needed.
- Participates in the development /administration of programs designed to enhance the utilization of targeted drugs and the identification of cost saving managed care pharmacy practices.
- Enters on-line approvals or denials of requests per departmental approved guidelines/standards.
- Provides support in obtaining clinical information for following programs: Drug Management Program, Coverage Determination Reconsiderations and 2nd level Appeals, and other programs as needed to support health plan initiatives.
- Speaks to HealthCare members on a daily basis regarding adherence and other pharmacy initiatives.
- Solves Rx claim issues with pharmacy providers/provider representatives
- Follows department P&P and SOPs to meet company goals and ensure compliance.
- Maintains department productivity and quality measures. Quality measures include but aren’t limited to Star Rating Initiatives such as Improving Adherence, Medication Therapy Management Completion of CMR, Statin use in persons with diabetes, and Acumen related reports around patient safety.
- Attends regular staff meetings.
- Assists with mentoring of new team members.
- Completes assigned work plan objectives and projects on a timely basis.
- Maintains professional relationships with provider community and internal and external customers.
- Daily rejection and paid file review that includes eligibility review, pharmacy/prescriber/member outreach, to resolve any issues with rejected claims.
- Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct. Consults with and refers cases to Pharmacy Director and/or medical directors regularly, as necessary.
- Complies with required workplace safety standards.
- Always conducts self in a professional manner.
- Expertise in Medical /pharmacy terminology, drug nomenclature, basic pharmacology, speaking to members about medication adherence, working with providers and pharmacies to assist in procurement of medications for members, quality initiatives, and pharmacy laws and regulations.
- Understanding of managed care pharmacy principles and insurance coverage issues.
- Demonstrated ability to communicate, problem solve, and work effectively with people.
- Excellent organizational skill with the ability to manage multiple priorities.
- Work independently and handle multiple projects simultaneously.
- Knowledge of applicable state, and federal regulations.
- Ability to take initiative and see tasks to completion.
- Computer Literate (Microsoft Office Products).
- Excellent verbal and written communication skills.
- Ability to abide by policies.
- Ability to maintain attendance to support required quality and quantity of work.
- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
- Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers
- High School Diploma or GED equivalent Completion of the Certified Pharmacy Technician Training Program
- Required License/Certification: Active license in good standing as a pharmacy technician with State Board of Pharmacy
- Minimum of 0-2 years of experience as a Pharmacy Technician in the ambulatory, community, home infusion, long term care or managed care setting required.
- Fluent in Spanish/English
- 0-2 years of healthcare industry experience (hospital, managed care, physician office, etc.).