Leads the clinical operations of the Pharmacy and Clinical Drug Management department and demonstrates/communicates the value of an integrated medical and prescription drug benefit to internal and external customers. Directs client, consultant, and/or broker interactions that support new business development including RFP/RFIs and retention of existing clients. Works closely with Chief Medical Officer and other Medical/Pharmacy leadership to ensure clinical alignment of drug management across medical and pharmacy benefits. Works collaboratively with various pharmacy areas and Care Management departments to ensure operational efficiencies of clinically directed interventions. Actively participates in various interdepartmental workgroup and/or committees defining and implementing relevant medical and/or prescription drug benefit structure and clinical programs. Acts in a leadership role on various projects, as assigned by management. Serves in a leadership capacity, as needed, and as directed by management.
• Directs clinical operations of Pharmacy & Clinical Drug Management department to ensure proper accuracy and efficiency.
• Develops and monitors the top-level pharmacy utilization and related financial index. Updates the Key Indicator Report for leadership review and decision-making.
• Assists with client-specific formularies and clinical operations (e.g., formulary management and initial reviews).
• Serves as the clinical subject matter expert on pharmacy and medical drug benefit management.
• Leads clinical and technical strategic, division, and department initiatives.
• Develops policies, procedures and standard operating procedures to improve and optimize the department’s efficiencies.
• Serves as liaison across Pharmacy and Care Management areas including Pharmacy Services, Pharmacy Programs, and Clinical Drug Management.
• Manages contracts, performance and relationships with vendor partners of clinical services.
• Monitors, evaluates, develops and implements quality initiatives (i.e., DUR programs) and drug cost management strategies.
• Participates in business and budget planning process and manages adherence to budget for clinical team.
• Designs and interprets client utilization reports. Recommends benefit changes or utilization management to assist clients in maximizing the value of their prescription drug benefit.
• Serves as the clinical pharmacy expert on a variety of committees and workgroups (i.e., Pharmacy Quality Management, Case Management Oversight, Utilization Management, etc.).
• Fosters strong relations with internal departments and external providers.
• Works with vendor PBM partner to improve on clinical pharmacy-related HEDIS scores.
• Partners with pharmacy areas and PBM to ensure solid handoffs for clinical and technical operations.
• Assists Pharmacy Services to ensure high service level to our members.
• Assists Pharmacy Programs to ensure benefits are positioned accurately from a clinical perspective.
Accreditation & Compliance
• Interprets standards published by national accrediting bodies. Gathers and documents supporting evidence demonstrating compliance with standards.
• Collaborates with external delegate(s) and Pharmacy & Clinical Drug Management department in regard to accreditation standard oversight
• Presents Pharmacy and/or Care Management programs and services to prospective clients, current clients, consultants, and/or brokers.
• Demonstrates the value of an integrated medical and prescription drug benefit to internal and external customers.
• Assists Pharmacy Programs, Sales, and Underwriting on business development and retention strategies.
• Ensures the materials, including RFPs/RFIs, representing the prescription drug benefits and medical drug management are accurate and positioned for success
• Analyzes data and identify gaps in care and services. Partners with the PBM to provide solutions.
• Assumes a leadership role representing the department or division in activities or projects. Reviews drug/medical literature, clinical practice guidelines, and available national guidelines to support drug policy development and consultation over various medical and pharmacy clinical programs.
• Provides internal professional staff and external provider education related to pharmaceuticals and program interventions.
• BS in Pharmacy from an accredited College/School of Pharmacy. Doctor of Pharmacy (Pharm.D.) preferred.
• Pharmacy practice residency desired.
• Current unrestricted license from the Ohio State Board of Pharmacy.
• Minimum five (5) years pharmacy practice experience in a managed care pharmacy setting (PBM or health plan) or equivalent.
• At least two (2) years in a client-facing role in a PBM or health plan (i.e., vendors, account management, business partners, etc.).
• Ten (10) years managed care pharmacy practice and/or third-party reimbursement or drug purchasing experience preferred.
PHYSICAL DEMANDS/WORK ENVIRONMENT:
• Performs work in an office environment
• Ability to travel occasionally based on business requirements.
We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse and tobacco testing.
Medical Mutual of Ohio - 19 months ago
Medical Mutual of Ohio is a not-for-profit managed care company that provides health insurance products and related services to some 1.6...