Managed Care Pharmacist – Managed Care/PBM

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as a consultant between Peak's business lines and clients to facilitate pharmacy benefit management operations.

• Deliver reporting to health plan leadership regarding pharmacy measure performance and gap closure.

• Create and execute clinical quality programs that address gaps in care related to industry standards and regulations.

• Design, implement, track, report, and assess PBM clinical program initiatives.

• Identify strategies to influence plan quality and achieve clinical goals and outcomes.

• Collaborate with internal teams, external clients, and the PBM on initiatives aimed at cost savings and quality improvement.

• Evaluate clinical program outcomes through data-driven analyses and pinpoint opportunities for enhancement.

• Partner with clinical, quality, and data analytics teams to ascertain and integrate data requirements and perform analyses.

• Serve as a liaison with the PBM and assist the Manager of Pharmacy Services in overseeing clinical and quality programs.

• Conduct quality assurance analyses of utilization management reviews.

• Engage in meetings with clients, external partners, clinical committees, and cross-functional workgroups.

• Provide support and guidance to pharmacy services staff.

• Contribute to the development of cost-saving strategies while optimizing clinical outcomes.

• Manage vendor relationships concerning Part D Stars measure performance.

• Ensure adherence to regulatory guidelines and reporting requirements.

• Monitor issues for potential processing improvements or educational opportunities.

• Attend external vendor meetings to discuss pharmacy objectives.

• Oversee PBM compliance with CMS metrics and key performance indicators for Medicare.

• Reconcile and report on Drug Management Program data related to overutilization.

• Address clinical eligibility flag discrepancies stemming from PBM PDE rejections.

• Support the pharmacy and formulary directory documents in alignment with CMS guidance.

• Act as a liaison between internal departments and PBM Client Account Executives to assist enrollees and resolve issues.

⛳️ Requirements

• Possess a current and unrestricted license to practice pharmacy in the state of residence.

• Have three (3) years of experience as a pharmacist in a managed care environment.

• Experience with pharmacy formulary strategy and design is preferred.

• Specific knowledge of CMS regulations, HIPAA, and the regulatory environment is preferred.

• Experience in developing and implementing Part D Clinical Interventions programs is preferred.

• Board Certification in managed care pharmacy and/or a managed care program certificate is preferred.

• Capability to stand and walk short distances for eight or more hours.

• Frequent bending, stooping, or stretching is required.

• Ability to lift 30 pounds and push 50 pounds.

• Capacity to perform under stressful conditions.

• Ability to handle and maintain confidential information securely.

• Proficient in working independently or cooperatively as part of a team.

• Familiarity with regulatory and accreditation standards.

• Ability to thrive in a fast-paced and rapidly changing environment.

• Extensive knowledge of Microsoft Office applications, especially Excel and Access.

• Experience with audits is required.

🏝️ Benefits

• Full-time employment.

• Exempt status.

• 40 scheduled hours per week.

• Reasonable accommodations may be provided for individuals with disabilities.

• Some travel to offsite meetings may be necessary.