CareFirst Careers

Clinical Operations Manager, Pharmacy (MD Medicaid)

Resp & Qualifications

The Clinical Operations Manager is supporting the CareFirst Maryland Medicaid Program

Position Summary
The Clinical Operations Manager is responsible for managing day-to-day operations of the Pharmacy Management department, providing guidance to and oversight of pharmacy staff, and directing the contracted Pharmacy Benefit Management (PBM) plus other vendor(s) under the general direction of the Director of Medical & Pharmacy Management (Director). The Clinical Operations Manager is also responsible for providing clinical expertise relative to the University of Maryland Medical System Health Plans’ (UMMSHP) pharmacy benefit programs, participating in designing, developing, and implementing clinical programs to promote a quality cost-effective medication use and manages all Pharmacy & Therapeutics (P&T) related process activities, and leads/supports quality initiatives to improve patient outcomes.  The Clinical Operations Manager is expected to assist department leadership with development and implementation of strategies, policies, protocols and systems that improve operational productivity, efficiency, and service.

Essential Duties and Responsibilities

  • Manage day to day operations for the Pharmacy Management department.
  • Respond to the Maryland Department of Health (MDH), U.S. Centers for Medicare and Medicaid Services (CMS), and other federal and state agencies as directed by the Director or other plan leadership.
  • Collaborate with the Quality and other departments in supporting quality initiatives and other related activities related to CAHPS, HEDIS, and STARS.
  • Lead meetings with the PBM and other vendors.
  • Support the Chief Medical Officer in managing the UMMSHP P&T and prepare P&T materials.
  • Lead the implementation of the formularies and PA guidelines, including benefit coding and formulary updates on websites, PA guideline implementation, member and provider communications, internal training alert communications, and follow-up on other pharmacy related initiatives resulting from the Committees’ decision(s).
  • Ensure appropriate health plan oversight of internal and vendor responsibilities related to prior authorization/coverage determinations, exceptions requests, complaints, and appeals and ensure criteria and decisions are properly communicated and applied.
  • Assist in ensuring pharmacy related processes are carried out in accordance with MDH, CMS, and other federal and state requirements and guidance, including executive orders, regulatory requirements, and administrative rules.
  • Prepare for annual submissions to and respond to other requests from MDH.
  • Prepare for submission of all Part D materials and reports to CMS and review the Part D Patient Safety Reports and other programs to improve Part D quality measures related to clinical pharmacy to raise the Medicare STAR ratings.
  • Coordinate/participate in activities related to improving outcomes for targeted disease focused initiatives leading to improved health (such as Asthma, Diabetes, Hypertension, Hypercholesterolemia, etc.), including medication therapy management program (MTMP) services.
  • Develop and implement programs or components of programs with internal departments, the PBM, and/or other vendors to improve the member and provider experiences, including efforts toward the plan’s population health and quality initiatives
  • Make presentations to and develop training, reports, and other communications for internal staff, members, providers, and to other stakeholders related to Pharmacy Management.
  • Oversee the creation and maintenance of the UMMSHP website contents, member/provider/internal communications in accordance with UMMSHP, NCQA, Medicare, and MDH requirements.
  • Guide the tasks performed by the Pharmacy Management team members and pharmacy students/ residents.
  • Provide pharmacotherapy expertise, review cases, and make formal recommendations at the request of the UMMSHP Medical Director/CMO.
  • Analyze pharmacy and medical utilization data to identify trends and at-risk populations; recommend and develop appropriate interventions; monitor and takes action on results.
  • Identify business process improvements that are aligned with and supportive of UMMSHP’s business goals and objectives, as well as provide thoughtful analyses and recommendations.
  • Act as a preceptor for pharmacy students and residents.
  • Create, update and maintain pharmacy program policies and procedures according to NCQA and other governing agency’s requirements.
  • Other duties as assigned by the Director or other health plan leadership.


Education, Experience, and Qualifications

  • Current and unrestricted Maryland pharmacist license required.
  • Education and formal training with Doctor of Pharmacy Degree (PharmD) from an accredited College/School of Pharmacy.
  • At least three years of experience in managed care, hospital, or retail pharmacy required.
  • Minimum two years involvement in formulary development, drug use evaluation, and quality improvement activities preferred.
  • Experience with developing and implementing clinical programs preferred.
  • Experience with Medicare Part D and Medicaid guidelines and requirements preferred.
  • Completion of a pharmacy practice or specialty residency (PGY1 or PGY2) preferred.


Knowledge, Skills and Abilities

  • Ability to work independently, exercising sound judgment, discretion and the initiative to facilitate change.
  • Ability to work well in an interdisciplinary team where you will be frequently asked to help resolve problems, foster an atmosphere of collaboration and team work.
  • Strong professional writing and verbal communication skills, including analytical abilities and citation skills.
  • Working knowledge of pharmacy and its related subdisciplines (therapeutics, pharmacology, physical pharmacy), formulary development, drug use review, quality assurance, legal, regulatory, and standards of practice.
  • Ability to research and analyze the medical literature including drug information, disease states, and clinical practice guidelines.
  • Excellent organization, time management, project management skills, multi-tasking abilities, diplomacy, and professionalism.
  • Willingness to “roll up one’s sleeves” and embrace the nitty gritty, bottom up task of building an organization and implementing a new model.
  • Personal and professional track record that demonstrates a commitment to quality in health care.
  • A positive attitude: ability to work hard, have fun, and operate efficiently in a fast paced, start up, work environment and in a highly complex and dynamic movement for health delivery reform.


Computer Skills

  • Strong proficiency in MS Outlook, Word, Excel, PowerPoint, Visio, and Access.

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

Closing Date

Please apply before: 12/16/2020

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.

PHYSICAL DEMANDS:

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

Learn more about Medical Management