Brief job information:
The Manager will direct and lead the Pharmacy Business Unit to strategize and implement an overall business plan, budget, and annual targets. The Manager is responsible for oversight of administrative and clinical aspects of the CCHP pharmacy benefit for Commercial, Exchange, and Medicare lines of business and maintenance of regulatory compliance with state and federal authorities. The Manager will directly manage staff responsible for day-to-day pharmacy operations, develop workflows and process between internal/external stakeholders, serve as the subject matter expect for audits, and advises on long-term strategy relating to pharmacy benefits.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Supervises the relationship with CCHP’s pharmacy benefit management (PBM) by serving as the lead on a variety of issues – administrative, compliance and clinical. Collaborates with the Medical Director and clinical team and the PBM to develop prior authorization criteria, pharmacy benefit coverage recommendations and formulary alternatives.
- Coordinates the quarterly Pharmacy and Therapeutics (P&T) Committee, which includes developing agendas, presenting clinical drug information and serving as a member of the P&T Committee. Monitors and analyzes prescribing patterns and drug usage. Reports findings and recommendations to the P&T Committee and implements approved steps to improve performance.
- Oversees the CCHP Commercial, Exchange, and Medicare Part D formularies. Conducts drug utilization review and monitors prior authorization trends to guide recommendations for additions or changes to the formulary. Employs clinical evidence-based methodology and cost-effectiveness considerations for drug coverage decisions.
- Collaborates with Quality Improvement Director to oversee the Medication Therapy Management (MTM) program and ensures that proper coordination occurs with all other CCHP care management programs. Reports to CMS and all other regulatory/contracted agencies the results of the MTM program, drug- disease interaction programs, medication intervention programs and any other pharmacy clinical initiatives.
- Interfaces with physicians to ensure ongoing communication and education via one-on- one meetings, group meetings, newsletter and targeted mailings to promote safe and cost- effective prescribing. Collaborates with physicians on identified medication or operational issues to improve patient access and therapy. Identifies outliers in physician prescribing patterns and provide transparency and data to reduce variation among peers.
- Leads pharmacy-related initiatives that support CMS, STAR, HEDIS measures, URAC quality improvement programs, and other initiatives. Collaborates with Medical Director in the integration of pharmacy and health management with medical quality improvement programs.
- Ensures compliance with state and federal regulations regarding the pharmacy benefit. Serves as primary pharmacy contact with CMS for Part D and DMHC for Commercial and Exchange, which includes phone calls, on-site audits, and additional correspondence. The Manager serves as an active member of the Business Oversight Compliance Committee.
- Collaborates with CCHP personnel: IT, medical management, claims; and network hospital systems, clinics, physicians and other stakeholders to improve compliant risk scores.
- In collaboration with Medical Director develops and implements programs to meet or exceed physician and hospital performance targets for improved risk adjustment scores. Presents progress and outcome reports on a regular basis; identifies gaps in performance and strategies to mitigate (monthly, quarterly and annually) to Medical Director, Committees, and other selected stakeholders.
- Develops an overall business plan and budget that will achieve specific goals/targets and deploys strategies to educate physicians/providers including metrics to monitor the effectiveness, success, and outcomes of each program.
- Strategizes and implements initiatives with Medical Director to maximize value-based care and reduce total cost of care. Leads projects to increase physician and patient awareness of quality, cost, and value to maximize informed decision making in selection of provider, service, and site.
- Achieves performance improvement objectives by communicating job expectations; planning, monitoring, and appraising job results; coaching, counseling, and implementing corrective action plans as appropriate; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards. Completes performance evaluations in a timely manner.
- Develops and implements action plans to address issues identified by the business units, including detailed work plans, issue logs, and progress reports.
- Develops and implements performance improvement policies, procedures, guidelines and programs. Develops and oversees strategies to promote quality, utilization and cost as well as to reduce practice variations.
- Accepts and performs other duties as assigned.
- Licensed CA pharmacist with demonstrated experience managing administrative and professional functions of a business unit of at least 3 people.
- 4 years of experience in the managed care field, 2 years of experience in a Manager position.
- Extensive experience in health plan and/or physician group model.
- Working knowledge of CMS and ACA risk adjustment, Clinical Documentation Improvement, coding and physician incentive programs.
- Continuous Improvement training preferred, with demonstrated experience in process improvement and efficiency.
- Possess a strong understanding of the current and evolving Federal, State and Local laws and regulations regarding healthcare delivery, risk adjustment as well as current knowledge of healthcare trends and best practices.
- Excellent research and analytical skills with ability to apply evidence-based principles to physician prescribing drug utilization and outcomes.
- Must be mission driven, clinically oriented, with strong integrity and the ability to serve as a role model and mentor to staff and other leaders
- Strong ability to communicate both orally and written in English and at all levels.
- Must possess critical thinking and problem solving skills, project management skills and the ability to make effective decisions.
- Ability to inspire and engage people and build strong relationships among staff and physicians.
- Strong ability to forecast healthcare trends and lead change within the organization.
- Ability to serve as a change agent and negotiator.