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). 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.
Within the Pharmacy department, the Clinical Pharmacy Program Specialist is responsible for supporting the ongoing daily operations of programs such as Comprehensive Medication Review (CMR) Tiers 1 and 2, the Behavioral Health Pharmacy Coordination Program, and the Specialty Pharmacy Coordination Program.
Under the direction of the CMR Program Director, this associate is responsible for managing all aspects of clinical pharmacy programs including day to day operations, vendor management, and operational reporting. The associate is accountable for managing collaborative efforts across various stakeholders and act as a liaison to meet Pharmacy Management business needs. The associate ensures alignment with the overall corporate vision and goals by focusing on compliance, procedures and monitoring/control to achieve program goals.
PRINCIPAL ACCOUNTABILITIES for the Clinical Pharmacy Program Specialist include, but are not limited to, the following:
Provides support for the end to end operations of clinical pharmacy programs.
• Manages all phases of the project life cycle process, which includes daily operations, monitoring progress, and serving as resource to divisional management regarding the project.
• Provides both verbal and written communications regarding project status, risks, issues, and makes recommendations on project decisions to Pharmacy Management leadership.
• Monitors claims payment activities and works with appropriate business leaders across the organization to ensure resolution of escalated claims issues.
• Develop SOPs as needed for materials and projects; maintain history of materials including dates and reasons materials were modified or removed from distribution.
• Coordinates and oversees all programmatic IT enhancements and requests.
• Provides regular updates to Pharmacy Program Directors on all aspects of operations and reporting.
• Proactively identifies risks and opportunities of both business and technical plans.
• Take the initiative to keep abreast of pertinent industry trends and competitors.
Develops and maintains a reporting system on clinical pharmacy program’s operational, clinical, and outcome metrics.
• Maintains the analytic infrastructure to evaluate the impact of the programs.
• Evaluates complex data findings, interprets data and provides analytical commentaries to explain or highlight significant findings to drive operational performance.
• Demonstrates ability to provide thorough analysis and recommendations on complex communication issues.
• Measures program performance by tracking activity and outcomes and are able to identify trends.
• Support Pharmacy Management in corporate-wide initiatives, including attending project meetings, providing strategic insight, presenting overview of initiatives to other associates and ensuring all commitments are met.
Collaborates with a variety of stakeholders and key partners internally and externally for the purpose of managing pharmacy programs.
• Acts as liaison across multiple areas to ensure effective and efficient goals, scope, progress and completion of projects. Work with the Pharmacy Management team to coordinate issues throughout CareFirst, and externally when necessary, to promote accurately represented information.
• Interact with all levels of Pharmacy Management, internal and external clients, and CareFirst support services (Legal, Operations, etc.). Respond quickly to accurately incorporate comments and requested changes. Provide updates to leadership as required.
Medical Pharmacy Management Program
• Assists with oversight and project management of the medical prior authorization and claims editing program performed by PBM vendor
• Assists with resolving medical prior authorization related problems
• Works directly with claims to analyze and resolve any medical claims related questions or issues.
• A Bachelor’s degree in HealthCare Management, Business, or a related field; or equivalent work experience required. A minimum of 2 years of project management or program evaluation experience required in a clinical setting or healthcare delivery related setting.
• Excellent oral and written communications; an ability to communicate and persuade customers, employees, and management at all levels.
• A proven track record of project management skills, effectively arranging resources and managing multiple small to large projects in a cross-functional environment.
• Strong organizational and business planning skills.
• Ability to analyze project needs and determine resources needed to meet objectives.
• Effective presentation, negotiation and influencing skills to interface with all levels of management.
• A keen attention to detail and the ability to prioritize and manage a variety of tasks simultaneously; sometimes under pressure and often with tight deadlines.
• Ability to establish strong relationships across departments, and with leaders at all levels, and an understanding of client needs, the consumer experience, marketing strategy and operational capabilities.
• Must be professional, organized, enthusiastic and a team player who can work independently 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 customer demands from internal and external customers, within set expectations for service excellence.
• Proficiency with multiple reporting applications and tools, including MS Excel, Access, Word, PPT and Project.
• Registered Pharmacist
• 2-3 years of health insurance experience
• Thorough knowledge of health care trends and experience working with pharmacy
• Vendor management experience
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: 1/18/2021
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 associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship