Pharmacy Medicare Coordinator

Jimmy Jazz; Olympia (WA); Vor Ort; USD 110.000 - 135.000; Vollzeit

Zusammenfassung

Jimmy Jazz is seeking a Pharmacy Medicare Coordinator to ensure operational compliance with CMS requirements and oversee Medicare functions. The role provides second-line oversight of delegated and internal operations and drives continuous improvement through audits and performance monitoring.

The ideal candidate brings deep Medicare knowledge and strong regulatory acumen, with the ability to collaborate across a matrixed organization to mitigate risk and support high-quality member outcomes.

Qualifikationen

• Bachelor’s degree or equivalent experience in healthcare.
• 5+ years of managed care pharmacy operations experience.
• 5+ years of pharmacy technician experience.
• Strong CMS regulation knowledge (42 CFR, Part D).
• Experience with PBM oversight, audits, or monitoring.
• Analytical, problem-solving, risk assessment skills.
• Knowledge of Stars measures and performance metrics.
• Experience presenting to leadership.

Aufgaben

• Provide oversight of Medicare activities to ensure CMS compliance.
• Monitor Medicare functions including claims, enrollment, and appeals.
• Evaluate performance against CMS standards and internal KPIs.
• Support CMS audits, data validation, and mock audits.
• Review CAPs from audits or performance gaps.
• Collaborate with Compliance and Legal on CMS guidance.
• Identify operational risks and trends via data analysis and reviews.
• Develop dashboards and reports for leadership on Medicare performance.
• Present findings and recommendations to senior leadership.
• Support Stars and quality improvement initiatives across programs.
• Partner with Operations, IT, Finance, and Quality teams.

Kenntnisse

Medicare regulatory expertise

Operational risk management

Influencing without authority

Continuous improvement mindset

Strategic thinking

Regulatory and compliance awareness

Cross-functional collaboration

Stakeholder communication

Risk management

Attention to detail

Data analytics

Project management

Self-starter

Ausbildung

Bachelor’s degree in healthcare administration, Business, Public Health, or related field

Equivalent experience

Tools

PBM claims systems

Tuva

Microsoft Excel

SQL

Jobbeschreibung

• Location 1300 EVERGREEN PARK DR SW,OLYMPIA, WA, 98502-5509,United States
• Base Pay $110,000.00 - $135,000.00 / Year
• Job Category Pharmacy
• Employee Type Full Time Exempt
• Required Degree 4 Year Degree
• Manage Others No

Job Summary

The Pharmacy Medicare Coordinator is responsible for ensuring operational compliance, performance excellence, and regulatory adherence within the Medicare pharmacy benefit. This role provides second-line oversight of delegated and internal operational functions, monitors compliance with CMS requirements, and drives continuous improvement through audits, issue management, and performance monitoring.

This role will also play a key role in utilization management and quality programs by pulling and reviewing data from internal and external sources. In addition, this role will take the lead in operationalizing utilization management or quality programs including project management, communications and monitoring results.

The ideal candidate brings deep Medicare operational knowledge, strong regulatory acumen, and the ability to partner cross-functionally in a highly matrixed organization to mitigate risk and support high-quality member outcomes.

Key Responsibilities

• Provide oversight of Medicare operational activities to ensure compliance with CMS regulations, contractual requirements, and internal policies.
• Monitor delegated and non-delegated Medicare functions, including claims, enrollment, appeals and grievances, utilization management, and pharmacy operations.
• Evaluate operational performance against CMS standards, KPIs, SLAs, and internal benchmarks.
• Support CMS program audits, data validation audits, mock audits, and readiness activities.
• Review and assess corrective action plans (CAPs) resulting from audits, compliance findings, or performance gaps.
• Partner with Compliance and Legal teams to interpret CMS guidance and ensure operational alignment with regulatory updates.
• Identify operational risks, trends, and systemic issues through data analysis, reporting, and oversight reviews.
• Identify utilization trends, and quality improvement opportunities through data analysis
• Run regular reports using SQL, Microsoft excel, Tuva and PBM claims systems
• Ensure timely escalation and resolution of compliance or operational concerns.
• Track remediation efforts and validate sustainable corrective actions.
• Conduct oversight reviews of delegated entities, including assessment of compliance, performance, and operational controls.
• Review delegated entity reports, audit results, and monitor outcomes.
• Collaborate with vendor management and business owners to address gaps and drive improvement.
• Develop and maintain dashboards, reports, and summaries for leadership related to Medicare operational performance and risk.
• Present findings, trends, and recommendations to senior leadership and governance committees.
• Support continuous improvement initiatives tied to Stars performance, member experience, and regulatory compliance.
• Serve as a subject matter expert for Medicare operational requirements.
• Partner with Operations, Compliance, Quality, Finance, and IT teams to support enterprise-wide initiatives.
• Contribute to policy and procedure development to ensure alignment with CMS requirements.
• Partner with sales and marketing to ensure member content is compliant and accurate.

Essential Skills & Qualifications

• Medicare regulatory expertise
• Operational risk management
• Influencing without authority
• Continuous improvement mindset
• Strategic thinking and execution
• Regulatory and compliance awareness
• Cross-functional collaboration
• Stakeholder communication
• Risk management
• Attention to detail and quality
• Change managementData analytics, including SQL, Microsoft excel, tuva and PBM claims systems
• Project management
• Self-starter. Ability to set priorities and keep to projected schedules.

Requirements

Required Education and/or Work Experience

• Bachelor’s degree in healthcare administration, Business, Public Health, or a related field (or equivalent experience).
• 5+ years of managed care pharmacy operations experience (Enrollment/ Billing/ UM/ Claims/ etc.)
• 5+ years of pharmacy technician (CPhT) experience
• Strong working knowledge of CMS regulations, including 42 CFR, Medicare Managed Care Manual, and Part D guidance.
• Experience with PBM operational oversight, audit readiness, or second-line monitoring.
• Proven analytical, problem-solving, and risk assessment skills.
• Knowledge of Stars measures and their operational impact.
• Familiarity with healthcare data reporting and performance metrics.
• Strong written and verbal communication skills, with experience presenting to leadership.

Preferred Education and/or Work Experience

• Experience with Medicare Part D
• Experience supporting CMS program audits or regulatory examinations.
• Experience with delegated oversight models.
• Experience creating and maintaining data dashboards
• Project management methodology (such as six sigma)

*PSW does not typically hire at the top of the pay range *