Introduction
To heal, to teach, to discover and to advance the health of the communities we serve.
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Overview
The Transitional Care Clinical Pharmacy Manager is a core clinical team member within Montefiore’s multidisciplinary Transitional Care Excellence department. This role sits at the intersection of inpatient care, ambulatory management, and population health, with a focus on improving outcomes for high-risk cardiovascular-kidney-metabolic and respiratory patient populations.
Responsibilities
- Leads longitudinal pharmacotherapy management for a defined panel of high-risk patients with cardiovascular-kidney-metabolic syndrome and respiratory conditions during hospitalization and post-discharge utilizing telemedicine, remote patient monitoring, and in-person care models.
- Initiates, optimizes, and titrates guideline-directed medical therapy (GDMT) under collaborative drug therapy management (CDTM) agreements, with a focus on heart failure, ASCVD, diabetes, obesity, CKD, COPD, asthma, and pneumonia.
- Identifies and acts on high-impact clinical opportunities early in the post-discharge period to prevent readmissions and disease progression.
- Solves complex medication-related challenges including access, affordability, adherence, and health-related social needs.
- Serves as a clinical bridge across inpatient, ambulatory, and post-acute settings, ensuring seamless care transitions and accountability across the continuum.
- Partners with physicians, advanced practice providers, nurses, and navigators to design and execute high-reliability care pathways.
- Acts as a key liaison to post-acute partners including home care, skilled nursing facilities, and rehabilitation centers.
- Contributes to quality improvement initiatives aligned with CMS Star Ratings, HEDIS measures, and value-based care contracts.
- Participates in program development, innovation (e.g., telehealth optimization, AI-enabled outreach, RPM workflows), and scaling of disease-specific care pathways.
- Engages in academic and scholarly activities including research, protocol development, and dissemination of outcomes.
Requirements
- Doctor of Pharmacy degree.
- Advanced training (e.g., completion of a PGY-2 residency in cardiology, ambulatory care, or other relevant specialties) or completion of a PGY-1 residency with current board certificationand 3 years of relevant experience.
- NYS license with eligibility to be credentialed as an allied health professional.
- Active Board of Pharmacy Specialties certification or completion within 6 months of hire.
- Direct patient care experience in ambulatory, hospital, or transitional care settings.
- Strong clinical judgment, communication, and interdisciplinary collaboration skills.
- Experience managing chronic cardiometabolic or pulmonary disease states.
- Experience in value-based care, care transitions, or population health programs.
- Bilingual language skills preferred.
Work Environment:
- Position requires onsite presence during onboarding, credentialing, training, and orientation.
- Initial six-month probationary period will be fully onsite.
- Following successful completion of training, credentialing, and the six-month probationary period, employees may be eligible for limited telemedicine or remote work responsibilities based on operational needs.
- Candidates must be comfortable working in both ambulatory and interdisciplinary care settings.
The ideal candidate will demonstrate:
- Strong clinical pharmacy knowledge and direct patient care experience.
- Ability to thrive in a fast-paced, complex healthcare environment.
- Excellent problem-solving and critical-thinking skills.