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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