Resp & Qualifications
PRINCIPAL ACCOUNTABILITIES: The position reports directly to the Director, Pharmacy Management (Medicare/Medicaid) and is a critical position within the unit responsible for understanding the pharmacy marketplace, opportunities for utilization management, and cost containment. The incumbent’s accountabilities include, but are not limited to, the following:
DUTIES AND RESPONSIBILITIES:
Manage Part D/Medicaid Formulary and Related Activities
- Review and recommend Medicare/Medicaid formulary that aligns with CareFirst’s business goals
- Collaborates with PBM on formulary development
- Works with PBM to ensure timely and accurate submission of all HPMS formulary and UM files accordance with CMS/MDH requirements
- Oversees PBM activities such as clinical decision making on utilization management
- Reviews guideline criteria for utilization management
- Supports all Medicare and Medicaid clinical formulary issues and inquires for internal and external stakeholders
- Monitors the accuracy and timeliness of coverage determination appeal requests.
- Monitors Star and HEDIS measures in collaboration with the Quality team to ensure formulary supports high performance
- Maintains list of Part B eligible drugs for prior authorization and step therapy
- Provides guidance for Part B vs Part D coverage determinations
- Oversees Transition program to ensure clinical functionality is implemented to support appropriate transition process for new enrollees
- Supports Medicare Part D and Medicaid websites including but not limited to formulary files, UM criteria, and negative formulary changes
- Participates in plan and regulatory reporting and audits
- Collaborates with the Government/Regulatory teams to assess impact of legislation to Medicare and Medicaid formulary and supporting pharmacy programs
- Continuously monitors evolving pharmacy marketplace and as new drugs come to market analyzes cost impacts and strategies for cost containment or clinical management
- Contributes to the development of educational materials, newsletters, member and provider talking points about clinical Medicare and Medicaid formulary management
Manage Part D and Medicaid Pharmacy Clinical Support Programs
- Monitor and oversee delegated clinical pharmacy programs including but not limited to operations, financials, and value realization
- Oversee the Part D Medication Therapy Management program, including vendor management and program submission to CMS
- Oversee the Medicaid Correcctive Managed Care (CMC) program
- Serve a key decision maker in clinical pharmacy program delegation and/or development to align with divisional goals
- Monitors Star and HEDIS measures in collaboration with the Quality team to ensure clinical programs support high performance
- Participates in the development and execution of initiatives to improve the Medicare Stars quality measures, especially focusing on medication adherence programs
- Contribute to the development of educational materials, newsletters, member and provider talking points about Medicare and Medicaid clinical pharmacy programs
Reporting & Value Realization Analysis
- Make formulary recommendations by assessing drug utilization trends, clinical guidelines, and drug spend
- Coordinates the development of appropriate drug use protocols and guidelines based on drug cost and trends
- Analyzes and reports value realization of clinical formulary management strategies.
- Identifies opportunities for improvement in clinical programs based on data analysis.
- Aid in the management of high cost specialty medications
- Graduate from an accredited School of Pharmacy, PharmD
- Active Maryland Registered Pharmacist.
- 5 years of clinical pharmacy experience in a health plan, hospital, PBM or similar role.
- Experience in Medicare and/or Medicaid.
- Previous experience in Part D formulary and/or Pharmacy & Therapeutic Committee management.
- 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 with and appreciation for working within the highly regulated healthcare industry.
- Proven record for driving to results through data-driven decision making.
- Thorough knowledge of managed care and pharmacy benefit management practices, including utilization management.
- A strong balance between clinical expertise and business acumen that will ensure the most expedient delivery of pharmaceutical management strategies and solutions.
- Exceptional project management skills and effective at leading in a matrix environment.
- Excellent strategic thinking and planning skills and the ability to develop and implement operational plans.
- Ability to shape Executive Management’s perspective on key Pharmacy programs by synthesizing key business, technical, and data driven points for successful program definition.
- 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: MD Medicaid -HEALTH SERVICES
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: 4/21/21
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