Mgr. Clinical Pharmacy Program

Harris Health System, Inc.; Houston (TX); Hybrid; USD 110,000 - 160,000; Full time

Job summary

Community Health Choice, Inc. is seeking a Clinical Pharmacy Program Manager to lead integrated clinical pharmacy services and oversee PBM-related operations for the health plan.

You will supervise clinical pharmacists and technicians, analyze claims data, and guide medication management initiatives across Medicare/ Medicaid/ Marketplace lines, ensuring regulatory compliance and optimal care. The role reports to the Director, Pharmacy Analytics-CHC and collaborates with Care Management and

Qualifications

• Active Texas pharmacist license required or licensure to be obtained before start date.
• Doctor of Pharmacy degree preferred.

Responsibilities

• Review claims data to identify utilization management opportunities and cost-savings.
• Perform prior authorization reviews and appeals.
• Oversee Medication Therapy Management (MTM) program and supervise pharmacy staff.
• Support Care Management and Utilization Management on medication-related projects.

Skills

Leadership

Communication

Analytical thinking

Attention to detail

Problem solving

Education

Doctor of Pharmacy (PharmD)

Texas pharmacist license

Tools

SQL

Microsoft Excel

Microsoft Office

Visio

Job description

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

JOB SUMMARY

The Clinical Pharmacy Program Manager provides highly specialized integrated clinical pharmacy services to the health plan. This position is responsible for managing both clinical and operational functions for pharmacy benefit administration for the assigned line of business. The Clinical Pharmacy Program Manager will be responsible for supervising clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned.

JOB SPECIFICATIONS AND CORE COMPETENCIES

Review medical and pharmacy benefit claims data for trends and outliers to identify opportunities to enhance medication UM strategies on high-cost drugs, formulary strategies, and Fraud, Waste, Abuse (FWA) reporting, lead Complex Medication Management program initiatives
Perform utilization management review of drug requests as assigned, including but not limited to prior authorization review, appeals, non-formulary exception and override requests
Analyze utilization and prior authorization data to identify drug utilization trends and cost-savings opportunities
Conduct oversight over prior authorization criteria and delegated utilization management functions performed by PBM
Serve as clinical resource supporting Care Management, Service Coordination, and Utilization Management functions on medication-related projects and inquiries
Manage the Medication Therapy Management (MTM) program
Supervise clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned
Actively contributes to achievement of departmental goals, including specific departmental process improvement plans, and other duties as assigned.
Review medical and pharmacy benefit claims data for trends and outliers to identify opportunities to enhance medication UM strategies on high-cost drugs, formulary strategies, and Fraud, Waste, Abuse (FWA) reporting, lead Complex Medication Management program initiatives
Perform utilization management review of drug requests as assigned, including but not limited to prior authorization review, appeals, non-formulary exception and override requests
Analyze utilization and prior authorization data to identify drug utilization trends and cost-savings opportunities
Conduct oversight over prior authorization criteria and delegated utilization management functions performed by PBM
Serve as clinical resource supporting Care Management, Service Coordination, and Utilization Management functions on medication-related projects and inquiries
Manage the Medication Therapy Management (MTM) program
Supervise clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned
Actively contributes to achievement of departmental goals, including specific departmental process improvement plans, and other duties as assigned.
Reports to Position Title: Director, Pharmacy Analytics-CHC
Employees Supervised Titles: Managed Care Clinical Pharmacist, Pharmacy Program Specialist

QUALIFICATIONS:

Education/Specialized Training/Licensure: Bachelor's degree in pharmacy if candidate does not have a Doctor of Pharmacy degree. (Bachelor's degree is not required if candidate has Doctor of Pharmacy degree.) required.
Active license as a pharmacist in Texas required; or will have Texas pharmacist license prior to start date required.
Doctor of Pharmacy degree preferred.
Work Experience (Years and Area): Minimum 5 years of applicable managed care pharmacy experience as a registered pharmacist;
or at least 4 years of relevant pharmacy experience AND completion of advanced training (i.e., completion of PGY1 managed care pharmacy residency, master, or doctorate degree in a quantitative discipline such as finance, accounting, business administration, or informatics)
Strong experience with drug utilization management required.
Minimum 4 years experience in Medicare, Medicaid, and/or Marketplace with a Health Plan or PBM required Experience with SQL preferred
Strong experience with medication management programs preferred
Work Experience (Years and Area): Minimum 5 years of applicable managed care pharmacy experience as a registered pharmacist;
or at least 4 years of relevant pharmacy experience AND completion of advanced training (i.e., completion of PGY1 managed care pharmacy residency, master, or doctorate degree in a quantitative discipline such as finance, accounting, business administration, or informatics)
Strong experience with drug utilization management required.
Minimum 4 years experience in Medicare, Medicaid, and/or Marketplace with a Health Plan or PBM required
Experience with SQL preferred
Strong experience with medication management programs preferred
Software Proficiencies: Microsoft Office (Word, Excel, Outlook, Power Point)
Experience with advanced Excel required
Visio preferred.
Job Family/Job Title Competencies
Problem Analysis
Results Oriented
Attention to Detail
Leadership
List any additional competencies not indicated above:
Exceptional Verbal and Written Communication
Managing Conflicts
Customer Oriented
Ability to work independently with minimal supervision
Taking initiative
INTERPERSONAL SKILLS
Ability to explain and communicate complex ideas with a diverse population.