Managed Care Pharmacist – Managed Care/PBM

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

📋 Description

• Assist with all aspects of the implementation of Pharmacy Benefit Manager (PBM).

• Facilitate communication with brokers and ensure the execution of the intended plan benefit design.

• Work collaboratively with stakeholders, clients, and the PBM to resolve issues.

• Provide education to clients and key stakeholders regarding pharmacy benefits.

• Aid in optimizing clinical outcomes while minimizing pharmacy expenses.

• Support quality assurance efforts for utilization management reviews.

• Monitor and evaluate clinical program outcomes.

• Create and implement clinical and quality program designs for the pharmacy benefit.

• Assess clinical and performance metric reporting.

• Analyze medication utilization.

• Manage formulary administration and the development of pharmacy benefits.

• Interpret benefits and analyze plan cost and utilization data.

• Oversee provider relations.

• Report on pharmacy measure performance and gap closure to health plan leadership.

• Design, implement, monitor, report, and evaluate clinical program initiatives for PBM.

• Identify strategies for cost savings and quality improvement.

• Conduct data-driven analyses of clinical program results.

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

• Carry out quality assurance analyses of utilization management reviews.

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

• Offer guidance to pharmacy services staff.

• Manage vendor relationships related to the performance of Part D Stars measures.

• Ensure compliance with regulatory requirements and reporting.

• Monitor processing issues and identify areas for improvement or education.

• Track PBM adherence to CMS metrics and key performance indicators.

• Reconcile and report Drug Management Program data.

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

• Support the development of the pharmacy and formulary directory in accordance with CMS guidelines.

• Act as a liaison between internal departments and PBM Client Account Executives.

⛳️ Requirements

• Must possess a current and unrestricted pharmacy license issued by the state of residence.

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

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

• Frequent bending, stooping, or stretching required.

• Must be able to lift 30 pounds and push 50 pounds.

• Ability to work effectively under stressful conditions.

• Must handle and maintain confidential information appropriately.

• Ability to work independently or collaboratively as part of a team.

• Familiarity with regulatory and accreditation standards.

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

• Extensive proficiency in Microsoft Office applications (Excel and Access).

• Experience with audits is preferred.

🏝️ Benefits

• Full-time employment opportunity.

• Exempt status.

• 40 scheduled hours per week.

• Reasonable accommodations provided for individuals with disabilities.

• Some travel to offsite meetings may be necessary.