PDP Program Associate

Job Description:

Job Description

The PDP Program Associate provides technical support and performs daily, weekly and monthly operational functions for the MedGenerations Prescription Drug Plan (PDP) department. This individual is well versed in all Part D related guidance as published by the Centers for Medicare and Medicaid Services (CMS) with extensive focus on CMS required communications, Medicare required programs and member relations.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Responds to client emails including Grievances and Salesforce cases in a timely fashion.  Establishes excellent working relationships with the Part D Sponsor, the assigned PDP Program Manager, the Account Teams and related client base.  Acts as an integral member of the client team, and attends client calls.

• Works closely with internal client and implementation teams in reviewing test claim results.

• Maintains a superior knowledge of the plan designs and benefit setups for clients as well as the CMS benefit standard. Assists with the claims and eligibility testing processes. 

• Provides client-facing support for Project Implementation and/or internal implementation support including Sales/Account Management support for Business Development.

• Provides operational support for PDP programs and services.

• Takes inbound calls and places outbound calls to members and other external entities to assist with member issues, member collections, Grievances, COB (Coordination of Benefits) notification and other member communications.

• Researches client or member issues related to the pharmacy benefit and provide resolution to internal and external customers including outreach to the pharmacy, facility and/or member.

• Research returned mail, logs outcome within internal systems, conducts member and pharmacy outreach to obtain updated information and mails out additional inquiries and/or mail pieces to the correct member address.

• Conducts denied claim review for all operational rejections and works with the member/pharmacy/client to resolve any issues.

• Creates and communicates task status to management and program managers.

• Creates policies and procedures and work instructions.

• Oversees and monitors related programs including True-up, FIR, COB, Hospice, ESRD, Excluded/Precluded Provider, OON, and Pharmacy Terminations along with any downstream processing including creation of all applicable reporting (in collaboration with other team members).

• Executes established SQL queries, extracting data from relational data bases and tables for purposes of audit support, issue identification and the generation of impact analysis.

• Provides “Data Validation” Audit support by working with the vendor. Acts as a subject matter expert for CMS reports; serves as a liaison with external auditors.

• Monitors and ensures accurate claims adjudication for denied claims and post-implementation monitoring.

• Tracks any assigned issues that are communicated to CMS and presents findings and remediation to the plan sponsor.

• Mentors and trains less experienced employees within the department.

Supervisory Responsibilities                                 

This job has no supervisory responsibilities.

Client Responsibilities This is an internal and external client facing position that requires excellent problem solving skills and strong communication skills (listening/verbal/written) in an effort to resolve member related issues and inquiries in a compliant manner.  One must be able to; Respond promptly to client and member needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients and members; Meet commitments to clients; Manage difficult or emotional client and member situations. Experience required in escalating and explaining complex situations to members and vendors to drive resolution

Education and/or Experience                                             

Associates degree (or equivalent combination of education and experience) with 5+ years’ related experience.  Prior experience in the PBM, pharmaceutical, or healthcare or health & welfare insurance industry required.    

Computer Skills

To perform this job successfully, an individual should have an intermediate to advanced knowledge of MS Project, Visio Project Management software and Microsoft Office Suite software.

Certificates, Licenses, Registrations

Pharmacy Technician, preferred, not required.

Other Skills and Abilities                                                    

• Knowledgeable in responding to CMS guidance changes
• Good understanding of Part D processes within cross-functional teams 
• Ability to learn and use MedImpact proprietary and vendor systems to research and solve enrollment and billing concerns

Reasoning Ability                                                    

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Mathematical Skills                                                 

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent and to interpret bar graphs.

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.  Ability to write reports, business correspondence, and procedure manuals.  Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.                 

Competencies                                               

To perform the job successfully, an individual should demonstrate the following competencies:

• Adaptability - Adjusts quickly to evolving situations by integrating new information, remaining flexible, recognizing and implementing necessary changes and taking advantage of opportunities presented by new developments.

• Business Knowledge - Demonstrates clear understanding of the nature of the business -- its products and services, goals, market, competitors and challenges. 

• Customer and Quality Focus  - Actively demonstrates a personal concern for understanding client needs, ensuring the quality of products and services, maintains a high level of customer satisfaction, and contributes to continuous improvement of products and processes.

• Customer/Client Focus - Shows solid grasp of characteristics and needs of both internal and external customers, interacts directly with customers, takes personal responsibility to ensure that customers’ concerns and needs are fully understood and addressed, and follows up to ensure customer satisfaction. 

• Initiative - Proactively gathers and analyzes information, assesses situations and identifies challenges and opportunities, sees what needs to be done and takes appropriate action.

• Interpersonal Effectiveness - Demonstrates good people skills by showing a commitment to teamwork, resolving conflicts effectively and with respect for others’ viewpoints, respecting differences and building strong relationships and networks.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The employee is occasionally required to stand; walk and stoop, kneel, crouch, or crawl.  The employee must occasionally lift and/or move up to 10 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Work Location

This position can be either on-site at the San Diego Headquarters, remote or a hybrid of both but will be responsible for providing adequate support to internal clients; coordination of work with other employees, colleagues, clients, or vendors; as well as for facilitation of quick and effective decisions through collaboration with stakeholders.  . 

Working Hours

This is a non-exempt position requiring one to be able to the hours required to fully accomplish job responsibilities and reasonable meet deadlines for work deliverables. The core business hours for this position are between 6:00 AM to 7:00 PM Monday through Friday.