<p>Pharmacy Benefits Specialist II - Medicare</p> <p>SummaCare - 1200 E Market St, Akron, OH</p> <p>Full-Time / 40 Hours / Days</p> <p>Hybrid - After Training</p> <p>SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.</p> <p>Summary:</p> <p>Monitors Pharmacy Benefits Manager (PBM) activities related to all lines of business, including Medicare Part D, Commercial and MarketPlace. Serves as a Subject Matter Expert (SME) for all pharmacy benefit questions, concerns, and issues from internal and external customers. Researches identified issues and works to resolve. Supports new benefit design, benefit build, testing, and implementation of market competitive, cost effective, quality based drug benefits which meet applicable federal and state regulatory requirements. Performs CMS required analysis of daily denied claims, coverage determinations, hospice and end stage renal disease (ESRD) claims. Provides research, data and member communication and resolution regarding all Part D grievances, including vendor oversite of such activities. Supports Pharmacist Program Coordinator in their medical benefit reviews and vendor management.</p> <p>Formal Education Required:</p> <p>a. Associates degree or equivalent college credits</p> <p>Experience & Training Required:</p> <p>a. Registered Pharmacy Technician License</p> <p>b. Certified Pharmacy Technician (CPhT) preferred</p> <p>c. Three (3) years performing same or similar responsibilities. Relevant experience includes: Health plan operations, pharmacy, or PBM positions.</p> <p>Essential Functions:</p> <p>1) Monitors and provides oversight of PBM activities including daily monitoring of coverage determinations, denied claims, hospice, and end stage renal disease (ESRD) claims.</p> <p>2) Serves as Subject Matter Expert (SME) for pharmacy benefits and drug medical benefits.</p> <p>3) Attends and participates in meetings with internal and external customers as it relates to pharmacy and coordinates support activities related to the Pharmacy and Therapeutics (P&T) Committee and formulary maintenance as required.</p> <p>4) Implements Medicare, Ohio Department of Insurance (ODI), and NCQA pharmacy regulatory changes.</p> <p>5) Provides research, data, and member communications and resolution regarding all Part D grievances including vendor oversite of such activities.</p> <p>6) Designs, builds and implements new Pharmacy benefits with the PBM and coordinates all delegated activities to the PBM.</p> <p>7) Performs all job functions with integrity. Provides timely internal and external customer service in cooperative, professional, and respectful manner.</p> <p>8) Supports Pharmacist Program Coordinator in their medical benefit reviews and vendor management.</p> <ol start="3"> <li>Other Skills, Competencies and Qualifications: </li></ol> <p>a. Demonstrate expert knowledge of Medicare Part D, ODI, and NCQA regulations.</p> <p>b. Effectively utilize MS Word, Excel, and other software applications to perform job duties.</p> <p>c. Make sound decisions and recommendations based on consideration of facts, priorities, resources, and alternatives</p> <p>d. Has ability to adjust work hours to meet business demands.</p> <p>e. Required to provide oversite of time sensitive member/provider requests including participation in a weekend on-call rotation.</p> <p>f. Organize and manage time to accurately complete tasks within designated time frames in fast-paced environment.</p> <p>g. Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity.</p> <ol start="4"> <li>Level of Physical Demands: </li></ol> <p>a. Sit and/or stand for prolonged periods of time.</p> <p>b. Manual dexterity to operate computer, phone, and standard office machines.</p> <p>Equal Opportunity Employer/Veterans/Disabled</p> <p>$20.90/hr - $31.35/hr</p> <p>The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.</p>