Pharmacy Program Manager - Medicare


Job Description

Manages the coordination of benefits in the pharmacy program with Medicare Part D plans. Provides the technical and leadership skills that ensure successful Part D pharmacy operations and program compliance within the pharmacy business unit. Makes business decisions that have impacts on members, providers, Part D plans, CMS, and the company. Requires a working knowledge of Medicare Part D eligibility requirements, Part D plan designs, drug formularies, drug pricing, claims processing and reimbursements, True Out of Pocket expenditures, that ensure successful Part D pharmacy operations and Senior Pharmaceutical Asistance Program compliance within the pharmacy department. Works with state program leaders, ensures established rules, policies, and procedures are implemented to ensure coordination of Medicare Part D operations are successful, efficient, auditable and in compliance with CMS requirements.
  • Ensures the accuracy of payments to Part D sponsors having signed agreements with the Pennsylvania Department of Aging (PDA), a qualified SPAP.  These payments include but are not limited to premium amounts, late enrollment penalties, and reimbursement of drug claims. 
  • Ensures the accuracy of payments to Part D sponsers for the Pennsylvania Department of Health's Aids Drug Assistance Program (ADAP) who has a memorandum of understanding with PDA to meet this objective.
  • Resolves disputes of payments with the Part D plans, on a timely basis, and acts as a liaison between PDA and the Part D plan.
  • Receives, interprets, and acts upon CMS guidance where necessary and applicable to the SPAP programs.
  • Consults with PDA staff members to identify and document business needs and objectives, and consults with internal staff and PDA staff members to identify and document current operational procedures, and evaluates alternatives applicable to system development activities. 
  • Provides technical assistance and guidance in identifying, evaluating, and developing systems and procedures, and tracks and documents changes to functional and business specifications.
  • Creates or assists others in the writing of user documentation, instructions, and procedures, assists in the creation and execution of acceptance test plans and the associated testing and monitors and documents post-implementation problems and revision requests. 
  • Assists PDA with writing the annual RFI and evaluating submitted responses from Part D plans.
  • Analyzes and interprets data and provides guidance in the plan selection.

General Job Information


Pharmacy Program Manager - Medicare



Job Family

Pharmacy Group


United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date


Date Requisition Created


Work Experience

Medicare, Operations


Bachelors: Business Administration (Required)

License and Certifications - Required

License and Certifications - Preferred

Other Job Requirements


  • At least five years of experience administering a pharmacy benefit for SPAPs and ADAPs coordinated with Medicare Part D.
  • Familiarity with all facets of the business, including but not limited to enrollment, invoicing, reconciliations, recoupment activities, electronic file submission and retrieval, and customer service.
  • Understands the impact coordination of benefits has on other operational areas including member and pharmacy call center customer service.
  • Excellent ability to communicate verbally and in writing to varied audiences including state government program leaders, Medicare Part D plans, pharmacy providers and members.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

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