Compliance and Operations Pharmacy Utilization Management Analyst

About the role

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.

Responsibilities

• 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
• Audit/Compliance and Reporting
• Makes daily, weekly, and monthly audit reports 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
• Serves as a subject matter expert for pharmacy utilization management applications, including working as a liaison between the business and IT teams
• Supports 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
• Identifies and presents 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
• 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
• Monitors process changes within the department that impact letters and file review standards, and monitors for compliance with changes
• 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
• Pharmacy Utilization Management Systems Support
• Aids management in the analysis, development, and design of improved automated tools and processes so that employees can more effectively perform their jobs
• Identifies and requests system enhancements, recommends priorities for requests, and develops requirements, testing, training, and implementation of application installments and upgrades
• Actively participates in system updates and testing of application and process changes as needed
• General Performance/Knowledge
• Participates in various workgroups, committees, and projects as needed and assigned
• Maintains appropriate confidentiality of information in accordance with HealthPartners corporate policies
• 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
• Identifies and appropriately communicates system issues, risk, and barriers to/needs for improvement to leadership

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 of quality standards and regulations
• Demonstrated comprehensive, in-depth knowledge, of corporate compliance requirements
• 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

Skills

• Knowledge of HealthPartners
• Knowledge of HealthPartners systems and applications
• Experience with Microsoft Access

Benefits

HealthPartners offers 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.

Pay

Competitive compensation package based on experience and qualifications.

Schedule

Full-time position.