Specialist - Pharmaceutical Benefit Management

4 weeks ago

Pretoria, South Africa H2R Africa Full time

One of our clients int he Healthcare industry has a vacancy open for a Specialist - Pharmaceutical Benefit Management to join their team.

Purpose of the position:

  • To perform drug utilisation review and actively manage and co-ordinate the approval of a members 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.

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.

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).
  • Minimum 3 years managed healthcare experience is essential.

Skills and Competencies Required:

  • 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 customer-service 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 critical-thinking 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 enroll in courses to broaden their knowledge on medicine and related conditions to optimally manage our clients.

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