Upper Peninsula Health Plan

The position supports the Upper Peninsula Health Plan (UPHP) Director of Pharmacy in ensuring the Pharmacy Department and its vendors remain fully compliant with all business, contractual, and regulatory requirements related to the pharmaceutical benefit. This position coordinates and supports pharmacy operations across all UPHP product lines, including drug benefit administration, claims management, utilization management, and reporting for both pharmacy point-of-sale processing and medical pharmacy services. Additionally, this position assists in identifying opportunities and developing strategies to enhance the efficiency, quality, and overall effectiveness of the pharmacy program. 

1. Follows established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.

2. Demonstrates and applies knowledge of all relevant Michigan Department of Health and Human Services (MDHHS), Department of Insurance and Financial Services (DIFS), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS®) standards, measures, and requirements as they relate to pharmacy functions and respective programs; assumes responsibility for meeting all compliance deadlines and requirements of assigned tasks. 

 

3. Assists the Director of Pharmacy in managing pharmacy compliance and operations, including prior authorizations, appeals, grievances, formulary management, drug claims and encounters, drug safety, and oversight of vendor relationships. 

 

4. Assists the Director of Pharmacy in all pharmacy-related compliance auditing, monitoring, and quality assurance activities and reporting, as assigned.

 

5. Assists the Director of Pharmacy in audit-related activities, including preparing and ensuring accuracy and timeliness of audit reports, materials, and submissions, as well as supporting the Director of Pharmacy in audit meetings. 

 

6. Develops, prepares, coordinates, reviews, and distributes applicable reports, policies, procedures, and communications for regulatory compliance, clinical, quality, financial, and drug utilization review.

 

7. Develops and maintains, in collaboration with Government Programs and the Pharmacy Benefit Manager (PBM), all required pharmacy materials for the UPHP website, ensuring content is accurate and regularly updated. 

 

8. Develops and maintains, in collaboration with Government Programs and PBM, all pharmacy-related member and provider materials, correspondence, and marketing to ensure compliance with state, federal, and regulatory requirements. 

 

9. Collaborates with internal teams – including pharmacy, customer service, utilization management, and clinical management – and external vendors and healthcare partners to resolve pharmacy-related issues and inquiries. 

 

10. Serves as the company liaison for identified pharmacy software application(s), composes training materials and procedures, and facilitates application training, ongoing support, and implementation upgrades to maximize the use of system functionality.  

 

11. Reviews and demonstrates knowledge of CMS Health Plan Management System (HPMS) and Pharmacy Benefit Manager (PBM) guidance and regulatory communications. 

 

12. Assists Pharmacists in preparing and performing outreach to members and providers related to pharmaceutical safety, drug recalls, and formulary management, documenting all interventions as required.

 

13. Assists in investigation and reporting of suspected fraud, waste, and abuse. 

 

14. Coordinates committee meetings, including preparation of materials and minutes, assuring timely and accurate completion in accordance with regulatory and accrediting standards.

 

15. Monitors, receives, and manages all pharmacy correspondence—including postal mail, fax, email, and Plexis Claims Manager (PCM) communications—and takes appropriate action as required.

 

16. Attends, participates, and serves on organizational and departmental committees as required.

 

17. Maintains confidentiality of client data.

 

18. Performs other related duties as assigned or requested.

 

Associate degree in health administration, business, pharmacy technology, or related field; 

equivalent combination of education and progressively responsible experience will be considered 

in lieu of a degree.

Bachelor’s degree in health administration, public health, pharmaceutical sciences, business 

administration, or related field; Certified Pharmacy Technician (CPhT) or other relevant 

credentials are favorable.  

Two (2) to three (3) years of experience supporting health system or business operations, including program management, data analysis, communications, billing, and/or related activities. Experience should demonstrate progressively responsible roles that include organizational support, coordination, and/or familiarity with healthcare or pharmacy functions. 

Three (3) to five (5) years of experience in health system or managed care environment related to program management, pharmaceuticals, pharmacy technician duties, claims processing, benefits administration, or other related activities. Experience should include progressively responsible roles that demonstrate knowledge of pharmacy operations, regulatory compliance, and collaboration with healthcare teams or external vendors. 

Experience with Microsoft Office (Word, Excel, & Outlook) 

Excellent attention to detail and problem-solving abilities 

Keyboarding proficiency

Excellent human relation and oral/written communication

Excellent organizational, prioritization, and self-management abilities

Experience in interpreting data from multiple sources

Advanced experience with Microsoft Excel functionality (e.g. Pivot table, VLOOKUP, mail-merge, etc.)

Knowledge of MS PowerPoint 

Knowledge of Pharmaceutical and Medical Terminology

 

 

Ability to enter and access information from a computer

Ability to access all areas of the UPHP offices

Occasionally lifts supplies/equipment

Prolonged periods of sitting

Manual dexterity 

Works in office conditions, but occasional travel may be required

Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration

Subject to many interruptions

Occasionally subjected to irregular hours