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.
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.
If you are qualified and seeking an exciting new challenge, please apply via Recruitment@jubileekenya.com quoting the Job Reference Number and Position by 17th September 2023
Apply via :
Recruitment@jubileekenya.com
