Pharmacy Cost Monitoring Technician

GENERAL DESCRIPTION: Responsible for the monitoring and implementation of regulatory processes such as Explanation of Benefits (EOB), Maximum Out of Pocket (MOOP), and Financial Information Report (FIR) transactions. Monitor monthly invoices, validate, and create Likely to Benefit (LTB) letters for the Medicare Prescription Payment Plan (MPPP) program. Manage Medicaid Pharmacy Claims, ensuring accurate transactions. These responsibilities are for all of the company’s business lines. ESSENTIAL FUNCTIONS: •Validate CMS regulations and proper implementation of EOB template, ensuring compliance and timeliness. Oversight procedures, member materials, reporting, resolutions, and summarizing lessons learned. Document, deploy, and execute initiatives to close all identified gaps. •Works in the process of timely reconciliation of FIR transactions to ensure accuracy with the PBM reports. For identified inaccuracies, ensure robust root cause analysis and effective corrective actions are performed and implemented on time. Perform trend analysis. •Monitor the Pharmacy Benefit Manager (PBM) and the cost accumulation, and ensure that claims are processed and adjudicated correctly; identify possible discrepancies, percentage in drug price change, drug formulary alternatives, copayments, COB, drug strength, eligibility file exchange, among others. •Evaluate rejections, correct and resubmit pharmacy claims (Medicaid) to ensure all transactions are properly submitted. Identify rejection causes and provide recommendations for potential deficiencies. •Create reports with metrics of pharmacy claims (Medicaid) rejections, corrections, and resolutions. Identify trends and recommendations to prevent future impact. Ensure data quality, compliance, and reduction of rejections. •Prepare Gap Analysis in situations required to identify gaps and underperformance within the process. •Validate possible members to enroll in the MPPP program, send LTB letters, validate invoices, and reconcile with PBM utilization, eligibility, and billing reports. •Monitors the Commercial line of business EOB for two groups. Validate eligibility information, demographics, claims, dates of service, drugs, and quantities. Ensure PBM sends letters promptly and provides shipment evidence. •Identifies transactions that reach the MOOP and performs claims tests to ensure members are not charged incorrectly. •Participate in and support internal and external audits. Update and follow internal policies. Complete reports for monitoring organizational metrics. •Follow up and monitor the time of referred pharmacy claims (Medicaid) rejections to corresponding areas, ensuring timely resolution. •Provide support to different units and/or departments in special projects and Ad Hoc requests. • Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. • May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Associate’s Degree in Pharmacy Technician. At least one (1) year of experience in data analysis and interpretation, and claims processing, preferably in the Healthcare Insurance Industry. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses: A valid Pharmacy Technician License and Registration is required. Other: N/A Languages: Spanish – Intermediate (comprehensive, writing and verbal) English – Intermediate (comprehensive, writing and verbal)