What you’ll do
In a few words…
Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning…
Providing high quality services to clients and beneficiaries is at the core of what we do every day! The PBM Operations & Services team is the very heart of Abarca and meets that standard by running services from MTM, price eligibility, configurations, and beneficiary services to government services and beyond. Our GPS, (Government Programs & Services) teams handle direct contact, data transfers, issue management, auditing, and much more for any state or federal agencies as well as government led programs. No one else in this division can talk the talk and walk the walk on Medicare and Medicaid services like they can!
As a Medicare Part B, Program Manager, you are the voice for key Government Programs, identified as the primary internal subject matter expert. You will have your finger on the pulse of critical programs and processes such as Part A and B pharmacy claims and coordination of benefits between Medicare and Medicaid. You will leverage your knowledge and experience to impact change. A Program Manager is energized by translating guidance into business processes and system requirements. You will also create and execute monitoring programs to ensure that CMS guidance is operationalized accurately and completely. In this role, you will employ your strong presentation and communication skills to work with other Abarcans and our clients to solve challenges and develop a better way.
The fundamentals for the job…
- Serve as Medicare Part B expert for pharmacy claims with internal and external stakeholders for key programs and processes.
- Consultative related to other critical Part A and Part B process such like ESRD, Hospice, B vs.D
- Engage directly with PBM and health plan clients as a subject matter expert and strategic consultant.
- Develop strategic workplans to achieve the highest possible quality in implementing key initiatives.
- Assess regulatory guidance and technical specifications to build or guide processes that ensure accuracy.
- Develop and monitor key performance indicators for performance improvement initiatives.
- Analyze deviations from expected results; determine root causes and implement corrective actions.
- Establish effective oversight and monitoring programs to ensure all client and CMS requirements are met.
- Participate in and facilitate requirements discussions related to changes that directly impact programs in scope.
- Identify and define enhancements to the program processes and logics.
- Prepare and maintain detailed process documentation for internal and external audiences.
- Develop internal and client training programs and cadence, facilitate execution.
- Engage directly with clients and leadership to develop, modify, and deliver dashboards and other required reporting as needed.
- Identify, quantify, and communicate areas of risk and develop corrective actions.
- Support creation of internal and external CAPs; oversee implementation of remediations, monitor efficacy of corrective actions.
- Collaborate with client implementation team for process requirements gathering, configuration, E2E testing and go-live process.
- Prepare ad hoc analysis and other reports such as RFP responses, presentations, among others.
What we expect of you
The bold requirements…
- Bachelor’s or Master’s degree in a relevant area.
- 6+ years of experience in Medicare Parts B and D Operations.
- Detailed experience within Medicare Part B and coordination of benefits for pharmacy claims; specific knowledge of pricing and claim processes.
- Experience with coordination of benefits across different payers within healthcare, insurance and/or pharmacy operations.
- Experience organizing and leading cross functional team projects and initiatives.
- Experienced in employing creative thinking to identify challenges, ideate potential solutions, and lead others in implementing changes.
- Experience defining and communicating business requirements with technical and non-technical audiences.
- Experience employing strategic thinking and planning mindset.
- Highly organized and adaptable, able to work in a fast-paced environment.
- Excellent oral and written communication skills.
- We are proud to offer a flexible hybrid work model which will require certain on-site work days (Puerto Rico Location Only)
Physical requirements…
- Must be able to access and navigate each department at the organization’s facilities.
- Sedentary work that primarily involves sitting/standing.
At Abarca we value and celebrate diversity. Diversity, equity, inclusion, and belonging are guiding principles of Abarca and ensure Abarca’s workforce reflects the communities it serves. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. “Applicant must be a United States’ citizen. Abarca Health LLC does not sponsor employment visas at this time”
The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.
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