Managed Care Pharmacist – Managed Care/PBM
Job Description:
- Serves as a consultant between Peak lines of business and clients to support pharmacy benefit management operations
- Provides reporting to health plan leadership on pharmacy measure performance and gap closure
- Develops and implements clinical quality programs addressing industry and regulatory gaps in care
- Designs, implements, tracks, reports, and evaluates PBM clinical program initiatives
- Identifies strategies to impact plan quality and clinical goals and outcomes
- Collaborates with internal stakeholders, external clients, and the PBM on cost-saving and quality improvement initiatives
- Assesses clinical program outcomes using data-driven analyses and identifies improvement opportunities
- Works with clinical, quality, and data analytics teams to identify and incorporate data needs
- Serves as liaison to the PBM and assists with oversight of clinical and quality programs
- Conducts quality assurance analyses of utilization management reviews
- Participates in client, partner, clinical committee, and cross-functional workgroup meetings
- Provides guidance to pharmacy services staff as needed
- Assists in developing cost-saving strategies while optimizing clinical outcomes
- Manages vendor relationships related to Part D Stars measure performance
- Ensures regulatory compliance and reporting
- Monitors issues for processing improvement or education opportunities
- Attends external vendor meetings
- Monitors PBM adherence to CMS metrics and key performance indicators for Medicare
- Reconciles and reports Drug Management Program data
- Resolves clinical eligibility flag discrepancies from PBM PDE rejections
- Supports pharmacy and formulary directory documents using CMS guidance
- Liaises between internal departments and PBM Client Account Executives for enrollee care and issue resolution
Requirements:
- Must possess current and unrestricted license to practice pharmacy issued by state of residence
- Three (3) years of experience as a pharmacist in a managed care setting
- Experience with regulatory and accreditation standards
- Extensive working knowledge of Microsoft Office applications (Excel and Access)
- Experience with audits
- Ability to work under stressful working conditions
- Ability to handle and maintain confidential information
- Ability to work independently or cooperatively as a team member
- Ability to work in a fast-paced and rapidly changing environment
- Ability to stand and walk short distances for eight or more hours
- Frequent bending, stooping or stretching
- Ability to lift 30 pounds and push 50 pounds
- Preferred: Board Certification in managed care pharmacy and/or managed care program certificate
- Preferred: Experience in pharmacy formulary strategy and design
- Preferred: Specific knowledge of CMS regulations, HIPAA and regulatory environment
- Preferred: Part D Clinical Interventions program development and implementation experience
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