Pharmacist: Medicare C&D Subject Matter Expert
Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.
Due to contract award, Qlarant has an opening on its Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC) team for a Pharmacist with subject matter expert (SME) level knowledge of Medicare Part C&D. This position could be home or office based. The PPI MEDIC Pharmacist provides subject matter expertise to the data, audit and vulnerabilities team. This will include developing methodologies to identify fraud, waste and abuse (FWA) in the Part C and D programs, analyzing utilization reports to identify new trends and patterns, and auditing plan sponsors’ coverage determinations. This position will also be called upon to provide outreach and education to the plan sponsor, other program integrity contractors, and/or law enforcement.
The ideal candidate should possess SME level knowledge of the Medicare Prescription Drug Benefit Manual, plan sponsor formulary management, and plan sponsor coverage determination processes. Self-starters with a strong sense of urgency, attention to detail and excellent communication skills make excellent candidates for this position.
The PPI MEDIC supports the Centers for Medicare and Medicaid’s FWA monitoring efforts in the Medicare Parts C and D programs by conducting proactive and reactive data analysis, identifying and recovering inappropriate payments, and identifying potential program vulnerabilities. The primary goal of the PPI MEDIC is to analyze Parts C and Part D data, conduct audits of plans, provide outreach and education to plan sponsors, and ensure compliance with regulatory requirements of Medicare Parts C and D.
Essential Duties and Responsibilities include the following in addition to those outlined above. Other duties may be assigned.
- Manages the day-to-day operations of assigned projects, as well as inter-project and cross-setting coordination of resources among projects; and contracts including facilitation and communication of resolution of barriers.
- Prioritizes, delegates, and accomplishes tasks and programs independently and in a team to ensure successful implementation of goals and objectives.
- Works with the appropriate stakeholders, drug plans, prescribers, and pharmacies within the pharmacy community to: build partnerships, support data sharing, develop tools and references to support changes in care practices in the pharmacy arena.
- Reviews and interprets contract deliverables to ensure timely and accurate completion.
- Leads the design and application of work plans, as well as coordinating their evaluation and any needed modifications to ensure they reflect project work.
- Contributes to the conceptual design and implementation of projects, as well as assist with project execution as needed.
- Ensures all project deliverables and timelines are met and reports on variances in a timely manner.
- May provide educational programs as necessary to meet project goals and promote high quality, safe, and effective medication use.
- May contribute newsletter articles applicable to project goals and community needs/requests; contributes abstracts for submission to national pharmacy, medical, and quality organizations; submit written manuscripts, as appropriate, to pharmacy, medical, and quality care journals for publication.
- May contribute professional presentations at national pharmacy, medical, and quality organization meetings.
- Ability to apply advanced mathematical concepts such as exponents, logarithms, quadratic equations, and permutations.
- Ability to apply mathematical operations to such tasks as frequency distribution, determination of test reliability and validity, analysis of variance, correlation techniques, sampling theory, and factor analysis.
- Ability to define problems, collect data, establish facts, and draw valid conclusions.
- Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
- To perform this job successfully, an individual should have an intermediate level knowledge of Microsoft Office to include Word, Excel, Outlook and PowerPoint; knowledge of Project Management software preferred.
Other Skills and Abilities
- Ability to work independently with appropriate coordination among project staff, partners and customers.
- Strong project management experience.
- Highly organized, able to work in a fast-paced environment, able to juggle multiple projects and assign proper priority, able to switch among tasks quickly and calmly.
- Excellent interpersonal skills and ability to work with and through people to get the job done.
- Registered pharmacist, Bachelor’s degree in pharmacy, with Master's degree in pharmacy or Pharm.D. Degree with three to five years experience in practice (retail, health-systems, consulting, industry or academia)
- Strong working knowledge of the Medicare Prescription Drug Benefit Manual, plan sponsor formulary management, and plan sponsor coverage determination processes
- Active, current and non-restricted Pharmacist license in at least one state.
- Knowledge of Microsoft Office to include Word, Excel, Outlook and PowerPoint necessary to meet contract deliverables
Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.