Managed Care Pharmacist – Managed Care/PBM
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Job Description
Managed Care Pharmacist overseeing PBM implementation, formulary strategy, and clinical quality programs. Optimizing pharmacy outcomes and reducing spend for Peak Health’s health plan operations.
Responsibilities:
- Support all aspects of Pharmacy Benefit Manager (PBM) implementation
- Broker communication and ensure execution of desired plan benefit design
- Collaborate with stakeholders, clients, and the PBM on issue resolution
- Educate clients and key stakeholders on pharmacy benefits
- Assist in optimizing clinical outcomes while reducing pharmacy spend
- Support quality assurance activities for utilization management reviews
- Monitor and assess clinical program outcomes
- Develop and implement clinical and quality program designs for the pharmacy benefit
- Evaluate clinical and performance metric reporting
- Assess medication utilization
- Oversee formulary administration and pharmacy benefit development
- Interpret benefits and profile plan cost and utilization data
- Manage provider relations
- Report pharmacy measure performance and gap closure to health plan leadership
- Design, implement, track, report, and evaluate PBM clinical program initiatives
- Identify cost-saving and quality improvement strategies
- Perform data-driven analyses of clinical program outcomes
- Liaise with the PBM and assist with oversight of clinical and quality programs
- Conduct quality assurance analyses of utilization management reviews
- Participate in client, external partner, clinical committee, and cross-functional workgroup meetings
- Provide guidance to pharmacy services staff
- Manage vendor relationships related to Part D Stars measure performance
- Ensure regulatory compliance and reporting
- Monitor processing issues and identify opportunities for improvement or education
- Monitor PBM adherence to CMS metrics and key performance indicators
- Reconcile and report Drug Management Program data
- Resolve clinical eligibility flag discrepancies from PBM PDE rejections
- Support pharmacy and formulary directory development using CMS guidance
- Liaise between internal departments and PBM Client Account Executives
Requirements:
- 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
- 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
- Ability to work under stressful working conditions
- Ability to handle and maintain confidential information
- Ability to work independently or cooperatively as a team member
- Experience with regulatory and accreditation standards
- Ability to work in a fast-paced and rapidly changing environment
- Extensive working knowledge of Microsoft Office applications (Excel and Access)
- Experience with audits
Benefits:
- Full-time position
- Exempt status
- 40 scheduled weekly hours
- Reasonable accommodations for individuals with disabilities
- Some travel to offsite meetings may be required
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