The Clinical Quality Pharmacist is responsible for creating and implementing data-driven, pharmacy-based strategies and workplans that improve the health, well-being, and quality of care and service received by our members. Success in this role is demonstrated by high quality measure performance in Medicare Part D and pharmacy-based HEDIS and CMS Star measures, with an emphasis on medication adherence, appropriate therapy initiation, and high-risk medication use reduction. This role uses outreach, education, care reminders, and prescription (Rx) prescribing support to engage patients and providers on the importance of medication therapy and adherence. The Clinical Quality Pharmacist collaborates with internal and external stakeholders, regional operations, IPA practices, employed sites, health plan payors, and other community partners to strengthen clinical relationships and engagement between members and the care delivery system. The focus of this position is to support and manage pharmacy-based quality metric performance, including but not limited to HEDIS, CMS Star Ratings, Medicare Part D gap closure, and CAHPS/HOS patient experience performance.
The ideal candidate will be:- Self-directed, able to manage multiple priorities, and coordinate complex cross-functional project plans, to drive execution of strategies
- Accountable for demonstrating improvement in quality, patient experience and optimized patient outcomes
- Skilled at utilizing data to drive decisions and has a passion for applying technology to achieve systematic solutions
- Passionate about continuous improvement, streamlined processes and workflow optimization
- Energized by new challenges, thrives in a fast-paced, dynamic environment, collaborates well in a collaborative atmosphere
Primary Responsibilities:- Under direction of the Medical Director, Quality Improvement and in collaboration with other stakeholders, the Clinical Quality Pharmacist will lead implementation of strategic pharmacy-based programs that improve the overall health and service provided to our patients. The goals of the program may include but is not limited to:
- Patient outreach and education (e.g., patients at risk of falling out of medication compliance for one or more medications, newly prescribed Statin Rx, PCP referrals)
- Managing patient outreach registries
- Counselling and educating patients regarding pharmacy benefits, health plan network and other programs and tools available to help improve quality of lifestyle
- Establishing a plan for each patient and/or patient opportunity cohort
- Coordinating auto Rx refills, multi-month Rx conversions, and mail order Rx
- Discussing patients' life issues affecting medication adherence and providing advice on improving drug regimen compliance
- Advising patients on alternate Rx fill strategies of retail versus mail order and options for financial assistance
- Provider/Clinician engagement to targeted clinicians with high volumes of patients with Part D Rx gaps and those needing education on the new Polypharmacy: Use of Multiple Anticholinergic (ACH) Medications in Older Adults, Concurrent Use of Opioids and Benzodiazepines, and additional emerging drug-related quality metrics as assigned
- Providing clinician education on measure requirements
- Reviewing strategies to reinforce Rx therapy and support Medication Adherence
- Offering clinician prescribing assistance, such as Prescribing Protocol Agreements to initiate / modify Rx on their behalf
- Liaising with provider offices on labs, refill orders and prior authorizations
- Reviewing and advising on medications and treatment plans (based on review of medical case notes, medication list and lab results) to improve outcomes and avoid potential drug interactions
- Outreaching providers in suspected medication abuse situations
- Reviewing medication regimens for disease states and providing summaries and guidance on future medication plans
- Accurate, concise documentation. Maintain quality of care standards as defined in workflow. Maintain compliance with quality standards, regulatory requirements, and organizational policies. Protect patient privacy and uphold confidentiality, ethics, and professional integrity at all times
- Optimize partnerships/ synergies with other accountable business units (e.g., Population Health, HP payors, Provider Relations, Clinical Services, Marketing, Legal/Compliance, etc.)
- Lead cross-team pharmacy-based program collaborations through detailed, time/role-specific project plans, to ensure clear consistent direction, communication, documentation, and division of responsibility
- Develop and implement performance improvement strategies related to quality and patient outcomes
- Provide Rx guidance and oversight of operational information and policy changes to internal departments
- Consistently support compliance by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licenser requirements (if applicable), and current corporate and client policies and procedures
- Coordinate and lead seamless collaboration with pharmacy technicians, providing mentorship and training as needed to optimize ongoing partnerships
- Partner with leaders and other functional business areas and other duties and initiatives as assigned
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- Active California Pharmacist license without restrictions
- 2+ years of experience with managed healthcare / care delivery business operations
- 2+ years of retail or ambulatory pharmacy experience
- Sound decision-making and time management skills to manage multiple programs with competing priorities and deadlines
- Ability to work both collaboratively and independently, without direct supervision
- Intermediate proficiency in Microsoft Office (Excel, Word, PowerPoint)
- Excellent verbal and written communication skills
Preferred Qualifications:- 2+ years of experience working with programs in HEDIS Quality, Stars, CAHPS/HOS
- 2+ years of experience in Population Health, Medicare Advantage, medication adherence, or Pharmacy Benefit Management (PBM) environments
- Familiarity with healthcare-related platforms (e.g., payor-specific systems, Epic EMR, Cozeva, or similar tools)
- Fluency in Spanish
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $91,700 - $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.
