Quality Auditor, Pharmacy','1704036','!*!About WellCare: WellCare Health Plans, Inc. is a Fortune 500 company traded on the New York Stock Exchange (symbol: WCG). It provides managed care services targeted to government-sponsored health care programs, including Medicaid, Medicare, Prescription Drug Plans and the Health Insurance Marketplace. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled. The company serves approximately 4 million members and employs approximately 6,500 people nationwide as of Sept. 30, 2014. For more information about WellCare, please visit our website at www.wellcare.com or view our videos at https://www.youtube.com/user/WellCareHealthPlan.EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.','!*!Department: Health Services
Reports to: Director of Medication Therapy
Location: 4110 George Road Suite 300 Tampa FL 33607
This position performs routine and complex quality audits of Pharmacy processes (coverage and member reimbursement determinations, redeterminations, Medication Therapy Management [MTM]). This role verifies the completeness and accuracy of technician’s casework, as well as adherence to federal and state regulations, accreditation standards, contractual requirements, and departmental policies, procedures and guidelines. Responsible for conducting scoring of casework, providing individualized feedback of audit results, and the identification of trending issues. Recommends improvements to departmental policies, procedures, guidelines and/or training practices as appropriate.
Conducts quality reviews of pharmacy coverage determination, member reimbursement determination, and redetermination processes.
Conducts quality reviews of authorizations originating from PBM systems associated with coverage determinations/redeterminations.
Conducts quality reviews of MTM technician and pharmacist processes (i.e. call handling, data entry, etc).
Reviews casework (all areas of Pharmacy) for thoroughness, accuracy, and compliance requirements in accordance with WellCare and any government (Federal or State) processes.
In conjunction with supervisor, coaches and provides written feedback to individuals and management based on error findings.
Tracks and maintains quality results for appropriate distribution.
Communicates audit results in a structured report format.
Demonstrates and applies subject matter expertise related to Pharmacy Operations processes for all WellCare lines of business (e.g. Medicare, PDP, Medicaid).
Assists with identification and communication of process improvement opportunities across pharmacy department.
Follows all state and federal regulations and contractual requirements, including record retention requirements.
Conducts ad-hoc projects as needed.
Performs other duties as assigned. Additional Responsibilities:
Required A High School or GED
Preferred A Bachelor's Degree in a related field Candidate Experience:
Required 3 years of experience in Pharmacy, Claims, Quality, or Customer Service related work
Preferred 2 years of experience in Pharmacy technician experience in a managed care, retail or hospital setting
Preferred 1 year of experience in Managed care pharmacy and/or appeals/grievances
Preferred 1 year of experience in Demonstrated experience supporting multiple pharmacy specialties (i.e. coverage determinations and/or redeterminations, MTM)
Preferred Other Familiarity with the pharmacy software utilized by WellCare and the PBM is a plus.
Preferred Other Previous experience with government programs such as Medicare and Medicaid Candidate Skills:
Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions Skills in workflow, reporting systems and databases
Intermediate Ability to work as part of a team Drug knowledge and/or knowledge of all workflow systems
Intermediate Ability to work independently
Intermediate Demonstrated written communication skills
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated time management and priority setting skills
Intermediate Demonstrated problem solving skills
Intermediate Other Ability to use pharmaceutical references
Intermediate Other Working knowledge of prescription medications and pharmacotherapy
Intermediate Other Ability to perform detailed review, research and analysis to ensure Operational accuracy across multitude of systems
Intermediate Other Demonstrated technical expertise in performing quality reviews along with analysis of results Licenses and Certifications:A license in one of the following is required:
Preferred Certified Pharmacy Technician (CPhT) Certified Pharmacy Technician Technical Skills:
Required Intermediate Healthcare Management Systems (Generic)
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Outlook
Required Intermediate Microsoft Word Languages:
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Website : http://www.wellcare.com
WellCare Health Plans, Inc. focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs. The company served approximately 3.8 million members nationwide as of Sept. 30, 2015. For more information about WellCare, please review our website and view the company’s videos. WellCare has developed a full complement of expertise in three major areas of government-sponsored health care…. Medicaid, Medicare Advantage and Medicare Prescription Drug Plans. Leveraging our expertise for our members' benefit is a key part of the value we bring to our members. WellCare focuses on those members who are dually eligible for both Medicaid and Medicare. This is an area of specialization that many other health plans simply do not have. We are committed to continually improving the quality of care and service that we provide to our members. We help our members access the right care at the right time in the appropriate setting. For some members, this includes the use of coordinated care teams and community partnerships. And we’re focused on government customers and use a disciplined approach to ensure a competitive cost structure.