Job Ref. No: JHIL093

Role Purpose

To supervise and provide guidance on all matters relating to pharmaceutical cost control and pharmacy benefits management.

Main Responsibilities

• Analytics – conduct regular analysis on claims patterns from providers to ensure proper adjudication within the stipulated policy terms. Conduct trending analysis; identify leakage; and prepare objective reports on claims and case processing processes.
• Develop and implement strategies for decreasing the company pharmaceutical expenditure.
• Pricelist Management – Monitor and evaluate prices to ensure provider adherence to the reasonable and customary rates and undertaking recovery measures where necessary.
• Developing quality control processes. Provide technical support to claims processing teams i.e., reimbursement team, quality assurance team, care managers and contact center representatives on clinical queries to ensure guided verdicts.
• Achieving medical quality assurance operational objectives by contributing information and analysis to claims strategic plans and reviews. Identifying problems, completing audits, determining system improvements, and implementing change.
• Training of relevant teams on pharmaceuticals or current treatment protocols where it is identified that there is a knowledge gap.
• Prepare pharmacy quality assurance documentation, presentations & reports. Analyzing and summarizing trends including failed processes, fraudulent activities, registered claims errors, corrective actions and re-validations on a weekly, monthly, quarterly, and yearly basis or as required by the business.
• Preauthorization of prescription drugs under stipulated parameters.
• Generic substitution – Advocate the use of generics where necessary as a method of reducing the co pharmaceutical expenditure targeting a reverse ratio.
• Poly-pharmacy – Enforce standard treatment guidelines in refence to the indicated diagnosis Discourage polypharmacy by diligently challenging of prescriptions and suggesting suitable alternatives.
• Provide technical support to claims adjudication teams i.e., reimbursement team, quality assurance team, care managers and contact center representatives on clinical queries to ensure guided verdicts.
• Drug Utilization Review – Advising clients and providers where adverse drug reactions are suspected or where potential of drug interactions exist and checking dosage and ensuring that medicines are correctly prescribed.
• Keeping up to date with the latest clinical guidelines for common ailments including non-communicable diseases as provided by Ministry of Health and other internationally recognized clinical bodies.
• Participate in formulation of appropriate CPT codes for medicines to track expenditure.
• Maintains pharmacological knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
• Maintaining knowledge of new developments in the pharmaceutical sector, anticipating potential negative and positive impacts on the business, and adapting strategy accordingly.
• Performs other related duties as assigned, which may be inclusive, but not listed in the job description.
• Form and foster strategic partnerships with relevant stakeholders to improve quality outcomes and cost-effective pharmaceutical care.

Requirements

Key Competencies

• Strategic thinking
• Analytical
• Creativity and innovation
• Negotiation
• Excellent analytical skills
• Performance reporting and management
• Training supervision and leadership

Qualifications

• Bachelor’s degree in pharmacy or equivalent.
• Registration with the relevant professional body.
• Basic understanding of the concepts of insurance
• Proficient in the use of Microsoft office suite and packages.

Relevant Experience

• At least two years in Clinical Practice.
• 5 years’ Relevant experience in Pharmacy Benefit Management.