Managed Care Pharmacist - Managed Care/PBM

Peak Health; United States; Sur place; USD 110 000 - 150 000; Plein temps

Résumé du poste

Peak Health is seeking a Managed Care Pharmacist to lead PBM implementation, broker communications, and ensure alignment with plan benefit design. The role educates clients on pharmacy benefits, optimizes clinical outcomes, and helps reduce spend while supporting QA activities in utilization management reviews.

Responsibilities include monitoring clinical program outcomes, collaborating with data analytics teams, and ensuring regulatory compliance across CMS guidelines and Part D initiatives.

Qualifications

• Must possess current and unrestricted license to practice pharmacy.
• Three (3) years of experience as a pharmacist in a managed care setting.
• Board Certification in managed care pharmacy and/or managed care program certificate.
• Experience with CMS regulations, HIPAA and regulatory environment.
• Part D Clinical Interventions program development and implementation experience.

Responsabilités

• Serves as a consultant between Peak lines of business and clients to support pharmacy benefit management operations.
• Provides reporting to health plan leadership on progress of overall performance of pharmacy measures and gap closure.
• Develops and implements clinical quality programs that address industry and regulatory health-related gaps in care.
• Responsible for goal design, implementation, tracking, reporting and evaluating overall effectiveness of the PBM clinical program initiatives.
• Identifies innovative strategies to impact Plan's quality and clinical goals and outcomes.
• Collaborates with key internal stakeholders, external clients, and Plan's pharmacy benefit manager to identify areas of potential cost-saving and quality improvement initiatives.

Connaissances

Regulatory knowledge

CMS regulations

Data analytics

Pharmacy operations

Part D Stars reporting

Experience in managed care pharmacy

Formation

Pharmacy license

Board Certification in managed care (preferred)

Outils

Excel

Access

Description du poste

Reporting to the Manager of Pharmacy Services, the Managed Care Pharmacist is primarily responsible for all aspects of implementation of the Pharmacy Benefit Manager (PBM), brokering communication, ensuring execution of desired plan benefit design, and collaborating with key stakeholders, clients, and the PBM on issue resolution. The Managed Care Pharmacist will also work directly with clients and key stakeholders to educate on pharmacy benefits and assist in optimizing clinical outcomes while reducing pharmacy spend. Responsibilities will include supporting quality assurance activities related to consistent and accurate utilization management reviews and monitoring and assessing clinical program outcomes. This includes development of clinical and quality program design and implementation for the pharmacy benefit. The Managed Care Pharmacist will assist in evaluating clinical and performance metric reporting and assessing the appropriate utilization of medications, and carries responsibilities that include oversight of formulary administration, pharmacy benefit development, benefit interpretation, profiling cost and utilization plan data, and provider relations.

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

MINIMUM QUALIFICATIONS

EDUCATION, CERTIFICATION, AND/OR LICENSURE

1. Must possess current and unrestricted license to practice pharmacy issued by state of residence.

EXPERIENCE

1. Three (3) years of experience as a pharmacist in a managed care setting.

PREFERRED QUALIFICATIONS

EDUCATION, CERTIFICATION, AND/OR LICENSURE

1. Board Certification in managed care pharmacy and/or managed care program certificate.

EXPERIENCE

1. Experience in pharmacy formulary strategy and design.
2. Specific knowledge of CMS regulations, HIPAA and regulatory environment.
3. Part D Clinical Interventions program development and implementation experience.

CORE DUTIES AND RESPONSIBILITIES

1. Serves as a consultant between Peak lines of business and clients to support pharmacy benefit management operations.
2. Provides reporting to health plan leadership on progress of overall performance of pharmacy measures and gap closure.
3. Develops and implements clinical quality programs that address industry and regulatory health-related gaps in care.
4. Responsible for goal design, implementation, tracking, reporting and evaluating overall effectiveness of the PBM clinical program initiatives.
5. Identifies innovative strategies to impact Plan's quality and clinical goals and outcomes.
6. Collaborates with key internal stakeholders, external clients, and Plan's pharmacy benefit manager to identify areas of potential cost-saving and quality improvement initiatives.
7. Assesses clinical program outcomes using data-driven analyses and determines opportunities for improvement.
8. Work with clinical, quality, and data analytics teams and others as needed, to ensure that data needs are identified and incorporated into the process including performing data analysis as needed.
9. Serve as the liaison to the PBM and assist Manager of Pharmacy Services in oversight of clinical and quality programs administered by PBM.
10. Conducts quality assurance analyses of utilization management reviews to ensure consistency and appropriate decisions in accordance with Plan policies.
11. Participates in meetings with clients and external partners
12. Participates on clinical committees and/or lead cross‑functional workgroups as necessary.
13. May provide guidance and direction to pharmacy services staff pertaining to responsibilities noted.
14. Assists in development of cost‑saving strategies while optimizing clinical outcomes.
15. Manages vendor relationships related to Part D Stars measure performance to ensure they are meeting contractual obligations and expectations.
16. Ensures compliance with all regulatory guidelines and reporting.
17. Monitors issues to find opportunities for processing improvement or education.
18. Attend external vendor meetings to communicate pharmacy goals and opportunities for reaching goals.
19. Assists Manager of Pharmacy Services in monitoring adherence of PBM to outlined metrics and key performance indicators outlined by CMS for the Medicare line of business.
20. Assist in reconciling and reporting data from Drug Management Programs to address overutilization of frequently abused drugs.
21. Resolves clinical eligibility flag discrepancies identified through PDE rejections received from the PBM.
22. Provide support and consultation for key documents such as the pharmacy directory and formulary directory, and referencing CMS guidance when applicable to creation of those documents.
23. Serves as a liaison between internal departments (such as care management) and PBM Client Account Executives to provide best‑in‑class care to enrollees and aid in issue resolution.

PHYSICAL REQUIREMENTS

1. Ability to stand and walk short distances for eight or more hours.
2. Frequent bending, stooping or stretching.
3. Ability to lift 30 pounds and push 50 pounds.

WORKING ENVIRONMENT

1. Standard office environment.
2. Some travel may be required to offsite meetings.

SKILLS AND ABILITIES

1. Ability to work under stressful working conditions.
2. Ability to handle and maintain confidential information.
3. Ability to work independently or cooperatively as a team member.
4. Experience with regulatory and accreditation standards.
5. Ability to work in a fast‑paced and rapidly changing environment.
6. Extensive working knowledge of Microsoft Office applications (Excel and Access).
7. Experience with audits.

ADDITIONAL JOB DESCRIPTION

• Scheduled Weekly Hours: 40
• Shift:
• Exempt/Non-Exempt: United States of America (Exempt)
• Company: PHH Peak Health Holdings
• Cost Center: 2405 PHH Medication Management