Specialist: Pharmaceutical Benefit Management

2 weeks ago

Pretoria, Gauteng, South Africa Recruitforce Group Full time

Our client, a managed care organisation based in Pretoria is looking for a Specialist: Pharmaceutical Benefit Management to join their pharmacy team.

This is an equal opportunity organisation with various businesses and/ or subsidiaries that service clients in the medical scheme and insurance industries.


Reporting to:
Specialist: Pharmaceutical Benefit Management

Location:
On-site at the Head Office, Pretoria

Contract Type:
Fixed-term Contract for period of 12 months (With the possibility of becoming permanent.

Salary:
Subject to experience, market related Cost to Company (includes benefits such as medical aid, pension fund

etc)

Purpose of the position:


To perform drug utilisation review and actively manage and coordinate the approval of a member's chronic medicine and to ensure that he/ she has access to this treatment within the available scheme benefit and medicine formulary.

To participate in the clinical review of existing treatment and, where appropriate, assist with motivation for exceptional funding for non-formulary medicines and to engage with various stakeholders - both internal and external.


Qualifications:

  • Registered Qualified Pharmacist Assistant (Post Basic)
- (Basic pharmacist assistant will not be considered for the position)

  • Valid registration with SAPC (paid up to date)

Skills and Competencies Required:

  • Minimum 3 years managed healthcare experience is essential.
  • Excellent knowledge of all 27 CDL conditions, including HIV medicine and treatment regimes.
  • Good knowledge of medicines to treat the 27 chronic disease list (CDL) conditions and clinical criteria requirements for
- each condition.

  • Computer literate
  • MS Office product suite, Outlook, Word, Excel, and pharmacy dispensing software systems.
  • Attention to detail is crucial.
  • Demonstrate excellent customerservice and organisational skills.
  • Strong telephonic and written communication skills (be able to manage difficult clients telephonically in a professional and
- calm manor).

  • Proficiency in English (speak and write will be tested).
  • Additional languages (speak) will be an advantage
  • Sesotho, Setswana, isiXhosa, isiZulu.
  • Competency in medical scheme medicine claim submissions, reversals, queries.
  • Be able to understand claim rejections and how to resolve them.
  • Handling complex queries effectively.
  • Problem identification and resolution.
  • Leadership skills, work independently and showing initiative.
  • Analytical and criticalthinking skills.
  • Strong reporting skills.
  • Ability to work well with others.
  • Ability to relate to people.
  • Excellent communicator with ability to influence others.
  • Basic business math skills and knowledge of mathematical/statistical concepts.
  • Ability to maintain confidential and/ or sensitive information.
  • Patient and a calm manner.
  • High stress tolerance.
  • Following through on commitments.
  • Results orientation.
  • Willing to enrol in courses to broaden their knowledge on medicine and related conditions to optimally manage our clients

Summary of Responsibilities:

  • Perform drug utilization review (DUR) on all new and/ or changed in chronic and acute prescriptions in accordance with
- the relevant medicine formulary.

  • Lower healthcare costs through DUR interventions where possible.
  • Communicate DUR to prescriber / member / pharmacy.
  • Identify and intervene on any drug interactions between disease conditions and medicine.
  • Assist with treatment counselling and disease management interventions for members who are registered on the HIV
- active disease risk management programme.

  • Resolve any medicine price queries with the relevant clearing houses/ pharmacy benefit manager (PBM).
  • Inform clearing houses (PBM) of prescription changes.
  • Follow up on additional information requested from clearing houses to complete members chronic registration and
- medicine authorization.

  • Be able to assist the medical scheme with paper claim pricing for member reimbursement.
  • Managing CPAP and stoma requests and loading of authorisations.
  • Prepare complex cases for clinical review for exceptional funding by the medical schemes.
  • Follow up on weekly medicine claim rejections to ensure members are registered and have access to medication.
Application Deadline: 2024/05/15

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