Compliance and Operations Pharmacy Utilization Management Analyst at HealthPartners Clinic Stillwater

Bloomington, Minnesota, United States -

Full Time

Start Date

Immediate

Expiry Date

05 Oct, 26

Salary

48.47

Posted On

07 Jul, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Pharmacy Utilization Management, Compliance Monitoring, Case Auditing, Regulatory Compliance, Technical Writing, Analytical Problem Solving, Project Management, Policy and Procedure Writing, Microsoft Excel, Microsoft PowerPoint, Microsoft Word, Microsoft Outlook, Data Integrity, Process Improvement, Stakeholder Communication, Audit Readiness

Industry

Hospitals and Health Care

Description

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 Utilization Management Program Develops and maintains knowledge of NCQA accreditation and delegation requirements, MDH audit requirements, CMS reporting and universe requirements, and CMS guidance as it relates to pharmacy utilization management reviews Understand process changes within the department that impact letters and file review standards, and monitors for compliance with changes Responsible for accuracy of data used to monitor compliance with turnaround times, letter standards, and notification standards Develops and executes monitoring and compliance activities with project management tools and approaches Communicates progress of monitoring program and issues for resolution to pharmacy prior authorization leadership team 204. Pharmacy Utilization Management Systems Support Assists management in the analysis, development, and design of improved automated tools and processes so that employees can more effectively perform their jobs Identify and request system enhancements, recommends priorities for requests, and develop requirements, testing, training, and implementation of application installments and upgrades Actively participates in system updates and testing of application and process changes as needed 205. General Performance/Knowledge Willingly participates in various workgroups, committees, and projects as needed and assigned Maintains appropriate confidentiality of information in accordance with HealthPartners corporate policies Develops and maintains positive, effective working relationships with prior authorization program review and support staff as well as other internal departments and applicable system software vendors Participates in ongoing independent study and education to develop and maintain knowledge in the areas of applicable software systems, regulatory and accreditation standards, quality improvement strategies and compliance requirements Demonstrates responsiveness to and appreciation of constructive feedback and recommendations for personal growth and development 10 *Job description rankings/percentages are intended to reflect normal averages over an extended period of time, and are subject to daily variances. Quality and efficiency standards should at no time be compromised to meet the average expectations expressed above. Job descriptions are subject to change to accommodate organization or department needs. MAJOR CHALLENGES: Responsible for the coordination and implementation of daily program management activities for Government Programs monitoring programs Needs to balance and manage demands of our customers (regulatory agencies, business partners with internal operational concerns, review staff) and quality and performance standards Facilitate interdepartmental compliance with program requirements Key resource for internal and external contacts on program administration Keep leadership and key partners informed of problems, concerns and trends that arise DECISION-MAKING: Manages daily work by determining priorities for multiple projects Identifies opportunities for/barriers to improvement, and communicates them to leadership for review and resolution Collaborates across multiple managers and areas for input and summation of issues and recommendations Prepares recommendations to various levels of leadership regarding conclusions and solutions to identified system issues Identifies and appropriately communicates system issues, risk, and barriers to/needs for improvement to leadership ORGANIZATIONAL EXPECTATIONS: Values All colleagues are expected to live our values: Excellence: We strive for the best results and always look for ways to improve. Compassion: We care and show empathy and respect for each person. Partnership: We are strongest when we work together and with those we serve. Integrity: We are open and honest, and we keep our commitments. Additional Expectations: Complies with safety instructions, observe safe work practices, provides input on safety issues, and promotes a safe work environment. Maintains regular and timely attendance Protects confidentiality Demonstrates participation in and support of the organization's Corporate Integrity Program by participating in compliance-related education and training and complying with the organization's policies and procedures. Timely completion of all mandatory education and organizational requirements (i.e., licensure/certification, Employee Health and Wellness requirements, annual training, etc.) At HealthPartners we believe in the power of good – good deeds and good people working together. As part of our team, you’ll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work. We’re a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improve lives around the world. At HealthPartners, everyone is welcome, included and valued. We’re working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change. Benefits Designed to Support Your Total Health As a HealthPartners colleague, we’re committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer a comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. Our goal is to help you thrive physically, mentally, emotionally, and financially, so you can continue delivering exceptional care. Join us in our mission to improve the health and well-being of our patients, members, and communities. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identify, status as a veteran and basis of disability or any other federal, state or local protected class.

Responsibilities

Develop and implement monitoring tools to ensure pharmacy utilization management compliance and audit readiness. Serve as a subject matter expert and liaison between business and IT teams for UM applications.