This position is primarily responsible for supporting Pharmacy Operations initiatives and strategies by directing and organizing programs, activities and supporting personnel in pharmacy operations. Works as part of the pharmacy team to implement and maintain pharmacy benefits and programs, and identify and resolve technical, operational, and vendor problems. Works on process improvements that improve the pharmacy operational efficiency. Maintains regulatory filings and website content.
- Responsible for delegation oversight of multiple PBM vendors for all lines of business (Medicare, Commercial, USFHP).
- Demonstrates strong understanding of Center for Medicare and Medicaid Services (CMS) requirements and regulations related to Medicare Advantage and Medicare Part D operations and compliance.
- Medicare Part D subject matter expert responsible for conveying applicable CMS regulatory guidance and expectations to staff within the pharmacy department. Consult with compliance divisions to provide strategic enterprise support.
- Interprets policies and procedures and establishes guidelines to support pharmacy programs and ensure regulatory compliance. Update departmental policies as needed.
- Informs and educates internal and external stakeholders on the features and services of the pharmacy programs.
- Supports achievement of the pharmacy program financial and clinical outcome goals.
- Supports internal and external audits.
- Makes strategic recommendations including benefit design and formulary analysis, provision of clinical drug information, oversight of delegated P&T functions, rational drug formulary positioning, online system edits and restrictions, on-going clinical product evaluations, and client pharmacy benefit utilization and performance trends.
- Participates on multidisciplinary quality and operational improvement teams as appropriate. Participates in meetings, serves on committees and represents the pharmacy department.
- Reviews key Part D key functions for evidence to document whether it meets compliance requirements for accuracy, includes, but not limited to: Claims, Coverage Determinations, Formulary Administration, PDE, and Reporting.
- Reviews Part D claims data for trends and financial impact to plan costs.
- Uses clinical expertise to lead development of program success measures and performs periodic assessments of programs for Part D / PBM/ Coverage Determinations.
- Performs oversight of Comprehensive Medication Reviews (CMR) for Medicare members as part of the vendors Medication Therapy Management (MTM) Program as scheduled
- Monitors STARs Measures.
- Performs other duties as assigned.
- BS or PharmD degree from an accredited College of Pharmacy
- Postgraduate training/residence OR Board Certification preferred
- Three (3) years of full-time experience in pharmacy operations in a managed care setting (e.g., health plan, PBM)
- PC skills (Word, Excel, PowerPoint and Outlook)
- Analytical skills with IT experience preferred
- Benefit coordination, managed care, drug utilization review.
- Experience with Medicare Part D, Commercial, TRICARE product lines.
- Experience with management of the pharmacy components of government programs.
- Experience working with PBM vendor systems.
C. Licenses, Registrations, or Certifications
- Current Pharmacy License in Texas, New Mexico, or Louisiana