Job Summary - Director, Pharmacy Client Services
This position is responsible for the overall success of employer group/agent engagements as it pertains to pharmacy. This includes year-end reviews, quarterly business reviews, finalist presentations, and various ad hoc meetings. This position directs pharmacy benefit operations and works with our pharmacy benefit manager on all aspects of our pharmacy programs and solutions. This position oversees the assessment and dissemination of market/competitor intelligence and the development of strategy and solutions.
Responsibilities:
Responsible for the success of pharmacy client engagements
Oversees group reporting and trend analysis
Surveil and assess market intelligence; partner with internal teams to develop competitive solutions
Oversee contracting, management, and reporting associated with group performance guarantees
Participate in presentations and education for internal stakeholders
Oversee pharmacy benefit operations and compliance with the regulatory parameters governing our business
Engage with our pharmacy benefit manager to ensure effective and efficient processes for benefit and formulary coding
Oversee group implementations and terminations
Serve as a SME in support of bids and requests for proposalPreferred skillset:
Thorough understanding of managed care pharmacy, especially with group commercial and individual markets
Excellent presentation skills, live and virtual
Deep knowledge of pharmacy benefit operations, formulary development, and trend management
Experience with managing projects and initiatives
Clear understanding of the regulations that apply to commercial and individual markets
Ability to analyze pharmacy data and interpret trends
DIRECTION EXERCISED
This position has direct oversight of the following: Operational oversight of the Pharmacy Benefit Manager, Medicare Part D Operations, Pharmacy Utilization Management and Coverage Determination. Directly supervises Manager Medicare Part D Operations, Manager Pharmacy Utilization Management and Pharmacy System Administrators.
Essential Functions
Engage in complex analytical and conceptual thinking to identify opportunities for operational efficiencies leading to increased customer experience and streamlined adjudication and prior authorization processes. Oversee and collaborate with direct reports to implement and carry out department strategies and objectives. Develop detailed plans and schedules, identifying goals, objectives, risks and resource allocation. Investigate future functionality and enhancement requests with pharmacy vendors.
Accountable for oversight of PBM performance expectations for benefit set-up, compliant claim adjudication, accurate formulary set-up, timely and accurate benefit set-up. Monitor performance for significant deviations in quality, cost or schedule. Collaborate with PBM to increase performance and establish return to service plans when PBM is under performing.
Develop department polices, procedures and standards of care that best align the department and Priority Health for current and future challenges, manage implementation of the same. Ensure close alignment with Director of Clinical Programs to ensure clinical decisions and policies are accurately documented and operationalized. Policies and procedures should support compliance with NCQA, CMS, Medicaid, HIPAA and PPACA. Effectively meet/exceed NCQA, CMS, HIPAA, departmental and other governmental requirements.
Compliant Operations for Medicare Part D Pharmacy Benefit including adherence to CMS regulations through detailed monitoring plans for Priority Health as well as first tier, downstream and related entries (FDR's).
Compliant operations and oversight of monitoring plan's pharmacy utilization management. Ensure staffing levels are sufficient to maintain service levels. Develop, implement and maintain performance tracking and trending tools to allow for daily monitoring of the team's performance level for all functions to ensure that departmental, CMS, Medicaid, NCQA and PPACA standards are met.
Project Management. Effectively develop, prioritize and implement project plans as assigned by management.
Budget. Pharmacy Operations Budget. Develop and monitor operating budget for Pharmacy Operations and Pharmacy Utilization Management, manage the budget to meet or reduce operating margin goals
Contract management with Pharmacy Vendors (PBM, Specialty Pharmacy, Previous PBM, Prior-Authorization Software vendor and any other vendors as assigned by AVP Pharmacy Programs.) Ensure contract is operationalized and adhered to as written by vendors. Oversight of Performance Guarantees, collaborating with vendors to meet or exceed performance goals. Create corrective action plans as needed for return to service levels.
Qualifications
Required Doctorate
7 years of relevant experience Pharmacy Benefit Administration, including Medicare Part D Required
7 years of relevant experience in a leadership role Required
5 years of relevant experience Experience working in an organization of size and pharmacy benefit complexity comparable to Priority Health Required
5 years of relevant experience Pharmacy and Medical Drug Review and Authorization Processes Required
5 years of relevant experience Contact Center Operations, including Medicare Contact Center/Utilization Management experience Required
5 years of relevant experience Progressively responsible experience managing Medicare program operations including high level of knowledge of CMS/Medicare regulations including oversight of compliance operations and... For full info follow application link.
Beaumont Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity, sexual orientation, age, status as a protected veteran, or status as a qualified individual with a disability.
