Director, Clinical Pharmacy Services - Priority Health

Priority Health; Grand Rapids (MI); On-site; USD 180,000 - 240,000; Full time

Benefits offered by this job

On-demand pay (Payactiv)

Comprehensive benefits package

Retirement plan with company match

Job summary

Priority Health in Grand Rapids seeks a Director, Clinical Pharmacy Services to administer and oversee Pharmacy Operations across Commercial, Self Funded, Medicaid, MIChild and Medicare. You will integrate Pharmacy Benefit Administration and lead policy development for compliant claim adjudication.

This role requires a Doctorate of Pharmacy, 3+ years in leadership and PBM experience, and strong knowledge of NCQA, CMS, HIPAA and PPACA.

Qualifications

• Doctorate of Pharmacy degree required.
• 3 years of PBM experience.
• 3 years in a leadership role.
• 3 years of experience in an organization of similar size and PBM complexity.
• 3 years of managing pharmacy programs and vendor relationships.

Responsibilities

• Oversee PBM performance, benefit setup, and formulary management with compliant adjudication.
• Develop policies and procedures aligned with NCQA, CMS, HIPAA and PPACA.
• Ensure Medicare Part D compliance and CMS monitoring.

Skills

Pharmacy leadership

PBM experience

Vendor management

CMS/NCQA compliance

Education

Doctorate of Pharmacy

Job description

About Priority Health

We are the second largest and fastest growing health plan in Michigan focused on improving the health and lives across the state, and we couldn't do it without the incredible talent of our employees. It is their commitment that continues to drive our success as a nationally recognized nonprofit health benefits company. As part of the Corewell Health system, our team members have a unique ability to grow and advance their career while maintaining their seniority and benefits.

About Priority Health

We are the second largest and fastest growing health plan in Michigan focused on improving the health and lives across the state, and we couldn't do it without the incredible talent of our employees. It is their commitment that continues to drive our success as a nationally recognized nonprofit health benefits company. As part of the Corewell Health system, our team members have a unique ability to grow and advance their career while maintaining their seniority and benefits.

The Director, Clinical Pharmacy Services administers and provides oversight for all aspects of Pharmacy Operations. Oversight includes all product lines of business; Commercial, Self Funded, HCR, Medicaid, MIChild and Medicare. This role will have oversight and successful integration of Pharmacy Benefit Administration. Benefit Administration includes, Pharmacy Benefit Manager, Medication Therapy Management, End to End Utilization Management Process, Part D CMS Compliance and Monitoring, Medicaid Compliance, NCQA Compliance, Health Care Reform Compliance, Prior Authorization Software, end to end benefit remediation and service recovery. The Director, Clinical Pharmacy Servicesdevelop policies, processes and business practices that support efficient and compliant Pharmacy Benefit Administration and claim adjudication.

DIRECTION EXERCISED

This position has direct oversight of the following: Operational oversight of the Pharmacy Benefit Manager.

Essential Functions

• Engage in complex analytical and conceptual thinking to identify opportunities for operational efficiencies leading to increased customer experience and streamlined adjudication and prior authorization processes. Oversee and collaborate with direct reports to implement and carry out department strategies and objectives. Develop detailed plans and schedules, identifying goals, objectives, risks and resource allocation. Investigate future functionality and enhancement requests with pharmacy vendors.


• Accountable for oversight of PBM performance expectations for benefit set-up, compliant claim adjudication, accurate formulary set-up, timely and accurate benefit set-up. Monitor performance for significant deviations in quality, cost or schedule. Collaborate with PBM to increase performance and establish return to service plans when PBM is under performing.


• Develop department polices, procedures and standards of care that best align the department and Priority Health for current and future challenges, manage implementation of the same. Ensure close alignment with Director of Clinical Programs to ensure clinical decisions and policies are accurately documented and operationalized. Policies and procedures should support compliance with NCQA, CMS, Medicaid, HIPAA and PPACA. Effectively meet/exceed NCQA, CMS, HIPAA, departmental and other governmental requirements.


• Compliant Operations for Medicare Part D Pharmacy Benefit including adherence to CMS regulations through detailed monitoring plans for Priority Health as well as first tier, downstream and related entries (FDR's).


• Compliant operations and oversight of monitoring plan's pharmacy utilization management. Ensure staffing levels are sufficient to maintain service levels. Develop,implement and maintain performance tracking and trending tools to allow for daily monitoring of the team’s performance level for all functions to ensure that departmental, CMS, Medicaid, NCQA and PPACA standards are met.


• Project Management. Effectively develop, prioritize and implement project plans as assigned by management.


• Budget. Pharmacy Operations Budget. Develop and monitor operating budget for Pharmacy Operations and Pharmacy Utilization Management, manage the budget to meet or reduce operating margin goals


• Contract management with Pharmacy Vendors (PBM, Specialty Pharmacy, Previous PBM, Prior-Authorization Software vendor and any other vendors as assigned by AVP Pharmacy Programs.) Ensure contract is operationalized and adhered to as written by vendors. Oversight of Performance Guarantees, collaborating with vendors to meet or exceed performance goals. Create corrective action plans as needed for return to service levels.

Qualifications

• Doctorate of Pharmacy Degree. Required


• 3 years of relevant experience Pharmacy Benefit Administration. Required


• 3 years of relevant experience in a leadership role. Required


• 3 years of relevant experience working in an organization of size and pharmacy benefit complexity comparable to Priority Health. Required


• 3 years of relevant experience Managing Pharmacy program operations and vendor programs. Required


• LIC-Clinical Pharmacist - State Other than Michigan Upon Hire required Or


• LIC-Clinical Pharmacist - State of Michigan Upon Hire required

How Corewell Health cares for you

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.


• On-demand pay program powered by Payactiv


• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!


• Optional identity theft protection, home and auto insurance


• Traditional and Roth retirement options with service contribution and match savings


• Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids

Department Name

Pharmacy Executive - PH Managed Benefits

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8 a.m. to 5 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.