Responsible for managing and providing expertise to support AlohaCare’s pharmacy management, which includes conducting operations meeting with the PBM, supervising department staff, interfacing with CMS for Part D deliverables etc. This involves close coordination and interface with the Plan’s Managers/Administrators, clinical departments, Provider Network, IS, as well as interaction with Med-QUEST. Ensures regulatory compliance in all areas related to pharmacy management.
Primary Duties, Responsibilities and Competencies:
Required Competencies and Qualifications:
- Review, update, and propose formulary operational changes quarterly.
- Work in concert with the appropriate AlohaCare staff to operationalize and implement and maintain care pathways for pharmacy outliers.
- Establish, implement, and maintain pharmacy utilization review reports and recommend strategies for operational improvement and monitor Plan objective with targeted strategies.
- Complete MQD’s Annual Pharmacy Reports, and other pharmaceutical reports as requested.
- Interface with AlohaCare’s PBM on operational, and limited IS issues to maximize Plan performance for pharmaceutical services.
- Work with appropriate AlohaCare staff to develop, implement, and maintain prior authorization operations and coverage review operations for AlohaCare’s formularies.
- Review all benefit plans and ensure changes and updates are operationalized (QUEST-Net, QUEST, ACA & ACAP).
- Work with the AlohaCare Provider Relations Department and Customer Service Department to collaborate with AlohaCare’s network of pharmacies and assist with pharmacy communications, provider and member relations regarding pharmacy operations and services.
- Provide advice and support for organizational activities and specific pharmacy projects and initiatives to control pharmacy costs while maintaining effective operations.
- Manage AlohaCare’s pharmacy management and provide staff with direction and supervision.
- Assist with the integration and continued operations of Pharmacy Benefits/Services within AlohaCare’s main IS platform.
- Establish, implement, and maintain P&P for Pharmacy services.
- Manage and assist pharmacy compliance in regards to URAC, HIPAA, CMS and other Federal and State rules and regulations for pharmaceutical services.
- Work with PBM to review operational activities related to formulary rebates, AWP pricing, MAC pricing, etc.
- Develop, implement and support organizational operations surrounding specialty pharmacy, home infusion and long term care pharmacy services.
- Respond to physician and pharmacists inquire when requested for operations by network providers to have peer to peer contact.
- Develop, assist and implement pharmacy reports that support case management/reporting activities for compliance with SHCN and the states quality strategy as designated by BBA.
- Assist with maintaining clinical formulary edits/rules such as step therapies, quantity edits, prior authorizations and coverage review criteria’s as they relate to operations.
- Filling position vacancies and managing pharmacy staff
- Establishing atmosphere of compliance with requirements within the department
- Preparing budgets and monthly variance explanations
- Signing off on check requests for departmental expenditures
- Hold bi-weekly departmental meetings documented with minutes – including sharing non-
confidential items of interests from Managers’ Meetings
- Participate in Managers meetings
- Participate in organizational workgroups or assigning other departmental staff to participate, as appropriate
- Perform duties of the department Lead during absences or vacancies
- Other duties as assigned.
Preferred Competencies and Qualifications:
- Doctorate degree from an accredited pharmacy college recognized by the American Council of Pharmaceutical Education (ACPE).
- Valid Hawaii Pharmacist license (must meet educational requirement(s) for Hawaii State licensure).
- 2+ years of experience in retail pharmacy.
- 5+ years of managed care experience.
- 2+ years supervisory experience.
- Proficient in Word, Excel and basic Access databases
- Learn and develop experience in the use of AlohaCare’s information system, QMACS, and AlohaCare’s historical data bases.
- Learn and develop experience in the use of the PBM’s claims and authorization processing platform/system, drug information, and reporting tools
- Ability to travel
An Equal Opportunity Employer
- Completion of an ASHP accredited general residency program