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Medicare Precert Pharmacy Program Manager

Primary Location: Arlington, Texas
Additional Locations: AR-Little Rock, NC-Charlotte, NE-Omaha, TX-Arlington, TX-Houston
This role will provide a variety of clinical and operational support to ensure that business objectives are met within the Medicare Precert department. This position works closely with functional area managers to facilitate appropriate and timely approval of pharmacy requests based on established clinical criteria.

Fundamental Components:

Develops and maintains internal department work aids, job aids, and clinical references to
ensure consistent and appropriate drug reviews and satisfy the compliance requirements of Medicare.Participates in formulary or benefit discussions.

Develops innovative solutions and applications to streamline workflows or processes for internal and external teams.

Conducts in-depth data analysis and works to develop solutions to address potential problems.

Ensures project implementations adhere to best practices for optimized quality of member care and reduced healthcare costs.

Maintains a solid understanding of Medicare Chapter guidance and remain current with medication knowledge and best practice protocols.

Provides on-going department support in research and analysis essential to resolving operational and quality concerns/issues raised by providers and other internal/external departments.

Competent to work with minimal supervision to interact effectively with other departments to achieve business goals.

Conducts coverage determination reviews, UAT testing,or other duties as required.

Background Experience:
  • 3 years In-depth knowledge and experience in managed care /PBM/ managed pharmacy / competitive environment ; Required
  • Previous (5-7 years) clinical pharmacy experience; Required
  • Data Analysis experience; Preferred
  • Call center experience; Preferred
  • A current, unrestricted Pharmacist license (RPh or Pharm.D) from an accredited school of pharmacy is Required
  • Degree in healthcare field; pharmacy degree Preferred.

Additional Job Information:

Position open to Telework across the US

Required Skills:
General Business - Turning Data into Information, General Business - Applying Reasoned Judgment, General Business - Ensuring Project Discipline

Desired Skills:
Benefits Management - Promoting Health Information Technology, Leadership - Anticipating and Innovating, Leadership - Creating Accountability

Functional Skills:
Communication - Provider communications, Customer Service - Customer Service - Pharmacy, General Management - Data analysis & interpretation, Medical Management - Medical Management - Legislative and regulatory compliance

Technology Experience:
Database - Microsoft Access, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Pharmacy - Licensed Pharmacist

Potential Telework Position:

Percent of Travel Required:
0 - 10%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests

Click To Review Our Benefits (PDF)


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