AmeriHealth Caritas Pharmacist II in Philadelphia, Pennsylvania
Location: Philadelphia, PA
Your career starts now. We’re looking for the next generation of health care leaders.
At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .
PerformRxis a Pharmacy Benefits Manager (PBM) dedicated to clinical culture, boutique service and holistic solutions. Our mission is to help customers, doctors and patients use effective medication therapy to improve health and wellness. For more than 15 years, our focus has been on providing optimal service through a clinical culture which seeks to provide members with high quality care while ensuring our partners receive favorable costs. That culture is reflected in our employees; more than 80 percent of our staff members are Pharmacists and Pharmacy Technicians, and in the services we provide.
PerformRxis headquartered in Philadelphia with offices on both coasts, leading to better pharmacy benefit management across the nation. Our dedication to innovation and to providing the most efficacious outcomes is the core of our clinical culture and is the heart of PerformRx. PerformRx is a subsidiary of the AmeriHealth Caritas Family of Companies.
Review clinical intent of change request form to ensure formularies will adjudicate at point-of-sale as expected
Work closely with claims processors to confirm that coding changes have been completed
Serve as the primary clinical point of contact for assigned lines of business which includes, but not limited to, coding based research and inquires, submission of coding to claim processor, validation of coding requests
Maintain plan formularies in claims processing systems
Serve as a lead for implementation for new lines of business and reimplementation for existing lines of business which includes, but is not limited to, establish and test adjudication rules, verify benefit structure, and validate adjudication outcomes
Participate in client audits (Medicaid, Medicare, etc)
Develop business and operations processes for clinical programs related to Medicare, Medicaid, Commercial and Exchange lines of business through interpretation of formulary requirements (i.e., step therapies, quantity limits, opioid edits)
Support the submission of assigned formularies to regulatory bodies
Represent the Clinical Operations department in multidisciplinary PerformRx meetings
Attend required training
Travel as required
Performs other job related duties and projects as assigned
Bachelor’s Degree required
Current pharmacy license; Pharm. D. preferred
Minimum one (1) years of Managed Care experience required
Minimum three (3) years of Pharmacy experience required
EOE Minorities/Females/Protected Veterans/Disabled
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