Resp & Qualifications
CareFirst, Inc. is a leader in the health care industry serving approximately 3.4 million individuals in Maryland, DC, and Northern Virginia. The Medical Affairs Division within CareFirst is responsible for what has become the largest Primary Care Medical Home program in the United States.
Surrounding and supporting the PCMH program is a larger infrastructure called the Total Care and Cost Improvement Program (TCCI). This program contains 20 key elements ranging from hospital transition of care and complex case management to home based services, review of high cost / high risk pharmacy cases and specialty review of complex cases.
The Pharmacy program is a central element of TCCI with Pharmacy itself being a critical component of CareFirst business, comprising nearly 32% of the overall medical spend. The Pharmacy department is primarily focused on strategic initiatives to improve quality and outcomes and decrease cost.
There are five key pharmacy functions that integrate with CareFirst’s Total Care and Cost Improvement (TCCI) and Patient Centered Medical Home (PCMH) programs to improve quality and outcomes and decrease cost. These strategic initiatives are the primary focus of the Pharmacy unit:
- Pharmacy Pricing – CareFirst obtained industry leading pharmacy pricing with regards to ingredient costs, administrative fees, and rebates through a competitive procurement of all major Pharmacy Benefits Management (PBM) vendors. To ensure the pricing stays ahead of market, CareFirst continually monitors claim history as a price check.
- Specialty Pharmacy Coordination Program - A dedicated Care Team (including nurses, pharmacists and care coordinators) works closely with members using Specialty Drugs for certain disease states (such as hepatitis C, rheumatoid arthritis, and multiple sclerosis) that must be administered according to rigorous treatment plans. This program optimizes Member outcomes through case management, refill reminders, and side effect management.
- Comprehensive Medication Review - CareFirst has partnered with its PBM partner to design a best-in-class medication management program for Members where there are indications of high potential for drug interaction, overdosing, side effects, etc. A pharmacist consults with the prescriber to assure a Member’s drug profile is optimal and resolve any issues with it.
- Formulary Alternatives – CareFirst offers three formulary options to large employer groups to more effectively manage cost while maintaining access and clinical efficacy.
- Within the Pharmacy unit, the Director, Comprehensive Medication Review (CMR) will support the development and maintenance of all key policies that guide the implementation of Total Care and Cost Improvement Program (TCCI) Pharmacy Programs. This position is responsible for overseeing and maintaining a Comprehensive Medication Review program, in partnership with our Pharmacy Benefit Manager (PBM), in order to effectively manage complex pharmacy patients.
The role requires collaboration with several key stakeholders listed below:
The Pharmacy team within the CareFirst Medical Affairs Division.
Core Business Partner, CVS Caremark (Pharmacy Benefits Manager). A range of internal CareFirst stakeholders including five market segment specific Strategic Business Units which support the operational aspects of Pharmacy, and other key units such as Sales and Marketing, Communications, Medical Affairs, Government Mandates, and others.
PRINCIPAL ACCOUNTABILITIES: The position reports directly to the Senior Director of the Pharmacy Evaluation & Oversight and is a critical leadership position within the unit responsible for reviewing the impact of medications for complex members. The Director of Comprehensive Medication Review will interact frequently with the EVP of Medical Affairs, the CEO, and other senior leaders across CareFirst. The incumbent’s accountabilities include, but are not limited to, the following
1. Operational Oversight for Effective CMR Programs
- Oversees and maintains a Comprehensive Medication Review program, in partnership with our Pharmacy Benefit Manager (PBM), in order to effectively manage complex pharmacy patients.
- Applies proper protocols to support the initiation of members into the CMR Program.
- Creates policy and guidelines in developing the program and collaborates with IT professionals within CareFirst who aid in delivery and execution of the program.
- Closely analyzes complex patients with regard to polypharmacy, drug interaction, high cost, and high utilization issues in order to eliminate gaps in member care and coordinate care with CareFirst’s PCMH/TCCI program.
2. Point of Contact for Medication Management Expertise
- Serves as the key liaison to internal and external stakeholders with regard to medication topics that require business input or clinical judgment about patterns in use, access and impact of medication use.
- Collaborates and communicates with stakeholders, adjusts business workflows as necessary, and explains program elements to a wide group of internal and external audiences/collaborators.
- Integrates and coordinates action between PCMH and Pharmacy.
3. Reporting & Value Realization Analysis Compared to Plan
- Develops criteria and repeatable metrics for reporting the value of all CMR Pharmacy programs.
- Assesses value through clinical outcomes, volume metrics, and financial savings from the program to assist in meeting strategic and departmental/plan goals and to identify gaps in analytical capabilities, and then recommend and create new capabilities to fill the gaps.
- Oversees the output and results from CMR program.
- Reviews the before and after snapshots of a member’s medication complexities and ensures that the proper clinical criteria is fed into CareFirst reporting systems.
- Drives the successful completion of CMRs and provides oversight and guidance to coordinate care for the members with PCPs, prescribing providers, and the PCMH team.
The Director of Comprehensive Medication Review is responsible for overseeing two clinical pharmacists and collaborating with the CVS Caremark team of external staff dedicated to perform not only the services required under contract, but also extensive collaboration to improve and expand pharmacy programs that create business value for CareFirst and its members.
- Graduate from an accredited School of Pharmacy, PharmD; MBA is preferred.
- Licensure in Pharmacy.
- 5-8 years of experience in a Health Plan or similar role.
- Exceptional project management skills and effective at leading in a matrix environment.
- Understanding of Medication Management and its effect on cost, trend and patient care.
- Strong understanding of contemporary clinical, operational, and regulatory pharmacy practices.
- Thorough understanding of prescription benefit management programs and practices, contracting, products/services, cost structures, pricing, and business practices.
- Experience in formulary management.
- Demonstrated success in clinical pharmacy program development, monitoring and quality improvement.
- Experience in pharmacy education and program development and planning including accreditation of programs.
- Experience in clinical technology assessment and implementation.
- Experience with and appreciation for working within the highly regulated healthcare industry.
- Ability to shape Executive Management’s perspective on key Pharmacy programs by synthesizing key business, technical, and data driven points for successful program definition.
- A strong balance between clinical expertise and business acumen that will ensure the most expedient delivery of pharmaceutical management strategies and solutions.
- Excellent strategic thinking and planning skills and the ability to develop and implement operational plans.
- Ability to identify priorities and achieve results with a sense of urgency and give honest straightforward opinions on related issues.
- Proficient at executive level relations and communications both within the company and with business partners, vendors, governmental representatives, and other Health Insurance Industry stakeholders.
- Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Department: Pharmacy Management
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 5/25/2018
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
- Must be able to work in an office setting, primarily seated while performing duties for a minimum of 8 hours per work day.
- Walking and standing is required. Lift weight up to 25 pounds on occasion.
- Hands are regularly used to write, type, key and handle or feel small controls and objects. Must be able to type and to speak on the telephone simultaneously.
- Must have the ability to communicate verbally effectively. Auditory ability is to actively listen.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship