Director, Clinical Pharmacy Services administers and provides oversight for all aspects of Pharmacy Operations. Oversight includes all product lines of business; Commercial, Self Funded, HCR, Medicaid, MIChild and Medicare. This role will have oversight and successful integration of Pharmacy Benefit Administration. Benefit Administration includes, Pharmacy Benefit Manager, Medication Therapy Management, End to End Utilization Management Process, Part D CMS Compliance and Monitoring, Medicaid Compliance, NCQA Compliance, Health Care Reform Compliance, Prior Authorization Software, end to end benefit remediation and service recovery. The Director, Clinical Pharmacy Servicesdevelop policies, processes and business practices that support efficient and compliant Pharmacy Benefit Administration and claim adjudication.
DIRECTION EXERCISED
This position has direct oversight of the following: Operational oversight of the Pharmacy Benefit Manager.
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 - Doctorate of Pharmacy Degree. Required
- 3 years of relevant experience Pharmacy Benefit Administration. Required
- 3 years of relevant experience in a leadership role. Required
- 3 years of relevant experience working in an organization of size and pharmacy benefit complexity comparable to Priority Health. Required
- 3 years of relevant experience Managing Pharmacy program operations and vendor programs. Required
- LIC-Clinical Pharmacist - State Other than Michigan Upon Hire required Or
- LIC-Clinical Pharmacist - State of Michigan Upon Hire required
How Corewell Health cares for you- Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
- On-demand pay program powered by Payactiv
- Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
- Optional identity theft protection, home and auto insurance
- Traditional and Roth retirement options with service contribution and match savings
- Eligibility for benefits is determined by employment type and status
Primary LocationSITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids
Department NamePharmacy Executive - PH Managed Benefits
Employment TypeFull time
ShiftDay (United States of America)
Weekly Scheduled Hours40
Hours of Work8 a.m. to 5 p.m.
Days WorkedMonday to Friday
Weekend FrequencyN/A
CURRENT COREWELL HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.You may request assistance in completing the application process by calling 616.486.7447.
