HealthPartners is currently hiring a Pharmacy UM Quality Specialist

This position supports quality of the overall product for the prior authorization program, including utilization management/utilization review. This role is focused on conforming to regulatory and accreditation standards specific to pharmacy utilization management (UM) reviews. The position provides timely and effective feedback and ensures quality of departmental prior authorization reviews via case auditing. Risk management and mitigation and quality monitoring are primary accountabilities.

 

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

 

 

 

 

Knowledge, Skills, and Abilities:

General understanding of all types of UM reviews for pharmacy prior authorization

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

High degree of initiative and ability to work independently and within a group

Excellent written and oral communication skills

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, 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

Minimum two years compliance background

    Knowledge, Skills, and Abilities: Knowledge of HealthPartners systems and applications

 

Essential Duties: % Of Time   1.

Quality Monitoring for Utilization Management Program

Maintains a thorough and comprehensive understanding of department processes and expectations to promote consistency, ensure adherence to, and maintain quality standards

Understands process changes within the department that impacts case processing, workflow, letters, and monitors for adherence with changes

Supports accuracy of data used to monitor adherence to turnaround times, letter standards, and notification standards

Support regulatory compliance by routinely reviewing coverage determination audit requirements

Develops and executes monitoring and compliance activities with project management tools and approaches

Communicates progress of monitoring program and issues for resolution to leadership team

50% 2.

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

25% 3.

Support Functions for Staff Training

Works closely with the other pharmacy staff to assure that training, procedures, task lists and quality standards are met

10% 4.

Pharmacy Utilization Management Systems Support

Actively participates in system updates and testing of application and process changes, as needed

10% 5.

General Performance/Knowledge

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

Demonstrates responsiveness to and appreciation of constructive feedback and recommendations for personal growth and development

Performs other duties, as assigned

5% (these are overarching duties incorporated in all daily work)

*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.

 

DECISION-MAKING: (What rules or precedents limit the activities and authority of this position? What types of problems or decisions are referred to the supervisor?)

Review of utilization review and utilization management cases against regulatory and contractual compliance, performance, and quality standards

Clear and concise communication with staff in a range of different positions

Appropriate notification to leadership team of regulatory trends and immediate issues

 

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.)