Job Description

HealthPartners is hiring a Pharmacy UM Compliance and Operations Analyst. 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. This position will also serve as a subject matter expert for pharmacy utilization management applications, including working as a liaison between the business and IT teams. This position provides support and coordination for the pharmacy utilization management team in maintaining a constant state of readiness for and compliance with regulatory and accreditation requirements.

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

Licensure/ Registration/ Certification: Knowledge, Skills, and Abilities:

Knowledge of quality standards and regulations

Demonstrated comprehensive, in-depth knowledge, of corporate compliance requirements

Ability to plan, organize, and prioritize work effectively, including the flexibility to accommodate frequent changes

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

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

Experience working with Compliance 360 monitoring tool

Licensure/ Registration/ Certification: Knowledge, Skills, and Abilities:

Knowledge of HealthPartners

Knowledge of HealthPartners systems and applications

Experience with Microsoft Access

Essential Duties:% Of Time (minimum 5% increments)1.

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

Assist with training of Pharmacy Customer Service Assistants as needed and assigned

202.

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

Support 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

Actively participate in audits and audit-related activities as required by NCQA, MDH, CMS, or other regulatory/accreditation agency

Identify and present 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

303.

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

Understand process changes within the department that impact letters and file review standards, and monitors for compliance with changes

Responsible for accuracy of data used to monitor compliance with turnaround times, letter standards, and notification standards

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

204.

Pharmacy Utilization Management Systems Support

Assists management in the analysis, development, and design of improved automated tools and processes so that employees can more effectively perform their jobs

Identify and request system enhancements, recommends priorities for requests, and develop requirements, testing, training, and implementation of application installments and upgrades

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

205.

General Performance/Knowledge

Willingly participates in various workgroups, committees, and projects as needed and assigned

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 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

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

10

*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.

MAJOR CHALLENGES:

Responsible for the coordination and implementation of daily program management activities for Government Programs monitoring programs

Needs to balance and manage demands of our customers (regulatory agencies, business partners with internal operational concerns, review staff) and quality and performance standards

Facilitate interdepartmental compliance with program requirements

Key resource for internal and external contacts on program administration

Keep leadership and key partners informed of problems, concerns and trends that arise

DECISION-MAKING:

Manages daily work by determining priorities for multiple projects

Identifies opportunities for/barriers to improvement, and communicates them to leadership for review and resolution

Collaborates across multiple managers and areas for input and summation of issues and recommendations

Prepares recommendations to various levels of leadership regarding conclusions and solutions to identified system issues

Identifies and appropriately communicates system issues, risk, and barriers to/needs for improvement to leadership

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.)

At HealthPartners we believe in the power of good – good deeds and good people working together. As part of our team, you’ll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work.

We’re a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improve lives around the world.

At HealthPartners, everyone is welcome, included and valued. We’re working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change.

Benefits Designed to Support Your Total Health
As a HealthPartners colleague, we’re committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer 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.

Join us in our mission to improve the health and well-being of our patients, members, and communities.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identify, status as a veteran and basis of disability or any other federal, state or local protected class.