Managed Care Pharmacist – Managed Care/PBM
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Managed care pharmacist overseeing PBM operations, formulary strategy, and clinical quality programs. Optimizing pharmacy outcomes and spend for Peak Health’s health plan clients.
Responsibilities:
- Serve as a consultant between Peak lines of business and clients to support pharmacy benefit management operations
- Provide reporting to health plan leadership on pharmacy-measure performance and gap closure
- Develop and implement clinical quality programs addressing industry and regulatory gaps in care
- Design, implement, track, report, and evaluate PBM clinical program initiatives
- Identify strategies to impact plan quality and clinical goals and outcomes
- Collaborate with internal stakeholders, external clients, and the PBM on cost-saving and quality-improvement initiatives
- Assess clinical program outcomes using data-driven analyses and identify improvement opportunities
- Work with clinical, quality, and data analytics teams to identify and incorporate data needs and perform analysis
- Liaise with the PBM and assist the Manager of Pharmacy Services 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
- Assist in developing cost-saving strategies while optimizing clinical outcomes
- Manage vendor relationships related to Part D Stars measure performance
- Ensure compliance with regulatory guidelines and reporting
- Monitor issues for processing improvement or education opportunities
- Attend external vendor meetings to communicate pharmacy goals
- Monitor PBM adherence to CMS metrics and key performance indicators for Medicare
- Reconcile and report Drug Management Program data addressing overutilization
- Resolve clinical eligibility flag discrepancies from PBM PDE rejections
- Support pharmacy and formulary directory documents using CMS guidance
- Liaise between internal departments and PBM Client Account Executives to support enrollees and resolve issues
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
- Experience with pharmacy formulary strategy and design (preferred)
- Specific knowledge of CMS regulations, HIPAA and regulatory environment (preferred)
- Part D Clinical Interventions program development and implementation experience (preferred)
- Board Certification in managed care pharmacy and/or managed care program certificate (preferred)
- 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, including Excel and Access
- Experience with audits
Benefits:
- Full-time position
- Exempt status
- 40 scheduled weekly hours
- Reasonable accommodations may be made for individuals with disabilities
- Some travel to offsite meetings may be required
Similar Jobs
Managed Care Pharmacist – Managed Care/PBM
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.
Lead Pharmacy Technician, IPU
Lead Pharmacy Technician coordinating IPU workflows, training, and staffing for Dragonfly Health’s care-at-home technology and pharmacy platform. Supporting accurate, reliable hospice and post-acute patient services.
Pharmacy Advisor, Representative
CVS Caremark Pharmacy Advisor supporting patients with medication refills, counseling opportunities, and cost savings. Handling inbound and outbound calls while coordinating clinical support and referrals.
Pharmacy Advisor, Representative
CVS Health Pharmacy Advisor supporting patients with medication refills, clinical questions, and care coordination remotely. Handling inbound and outbound calls while maintaining accurate health records.
Pharmacy Advisor – Representative
Pharmacy Advisor supporting CVS Caremark members with medication refills, cost savings, and clinical service calls. Handling inbound, outbound, and fax requests from home.
Senior Manager, Pharmacy
Senior Pharmacy Manager overseeing PBM vendors, formulary strategy, and clinical programs. Driving affordable, high-quality health benefits and member outcomes at Gravie.
Clinical Pharmacy Specialist
Remote clinical pharmacist delivering medication management for Shields Health Solutions’ integrated specialty-pharmacy patients. Supporting virtual assessments, therapy optimization, and collaborative care across the Centralia/Olympia/Lacey area.
Pharmacy Technician Services Associate
Pharmacy technician supporting Conduent’s healthcare services and customer accounts. Handling eligibility calls, prescriptions, prior authorizations, and escalated patient concerns remotely.
Pharmacy Technician
Remote Pharmacy Technician supporting TEKsystems’ Medicare Advantage clients by closing medication-adherence gaps. Conducting high-volume outbound calls to diabetic members.
Pharmacy Technician
Remote Pharmacy Technician supporting TEKsystems’ Medicare Advantage medication adherence outreach. Closing diabetic members’ care gaps through high-volume outbound calls.
Pharmacy Technician
Remote Pharmacy Technician supporting TEKsystems’ Medicare Advantage care-gap programs. Making high-volume outbound calls to improve diabetic member medication adherence.
Claims Pharmacy Technician
Remote Pharmacy Technician processing failed claims and dispensing medications for CenterWell Pharmacy. Maintaining inventory and supporting safe, reliable home-delivery pharmacy services.
Central Prior Authorization Pharmacy Tech
Pharmacy technician coordinating specialty-drug prior authorizations for Apotheco’s pharmacy services. Managing payer submissions, documentation, insurance verification, and prescription access remotely.
Pharmacy Assistant
Pharmacy Assistant processing prescriptions and coordinating specialty medication deliveries for Canadian patients. Supporting Sentrex Health Solutions’ pharmacy and patient support services remotely.
Pharmacy Consultant
Pharmacy Consultant advising employee benefits clients on PBM strategy, pricing, and pharmacy programs. Supporting consulting projects, client deliverables, and new business initiatives.
Pharmacist – Hemophilia
Hemophilia pharmacist supporting specialty medication access and therapy for Centene’s health plan members. Providing clinical monitoring, counseling, prescription review, and patient care coordination remotely.
Pharmacist – Specialty
Specialty Pharmacist managing medication therapy, counseling, and clinical monitoring for Centene’s 28 million healthcare members. Supporting safe dispensing and pharmacy quality programs remotely across five U.S. states.
Pharmacy Coordinator – FWA
Pharmacy Coordinator reviewing fraud, waste, and abuse referrals for Centene’s health plans. Analyzing pharmacy data, supporting investigations, and coordinating member, provider, and pharmacy inquiries.
Pharmacist
Pharmacist reviewing medication safety, dosing, and contraindications for Mercor’s AI-training projects. Applying Lexidrug expertise to evaluate clinical conclusions and documentation.
Senior Integrated Clinic Pharmacist
Clinical Pharmacist optimizing medication therapy for seniors at CenterWell, a value-based primary care provider. Supporting chronic-condition management, patient education, quality measures, and integrated care teams.