Director Clinical Pharmacy Strategies - Medicare Star Strategy and Execution

Anticipated End Date:

Position Title:

Job Description:

Director Clinical Pharmacy Strategies - Medicare Star Strategy and Execution

Location: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Director Clinical Pharmacy Strategies is responsible for leading a Medicare Clinical team in the development, implementation and evaluation of Medicare CMS Star and CAHPS clinical interventions, cost of care management strategies for Medicare business segments. This role will oversee Medicare CMS Star management initiatives and processes that impact health care quality, cost of care, and outcomes for all aspects of the retail and medical benefit. In addition, this role will also oversee the pharmacy CMS Star Portfolio including enterprise and contract level strategy execution and performance while maintaining compliance with all related regulations and guidance.

How you will make an impact:

• Lead a team who establishes and executes Medicare CMS Star clinical intervention programs to achieve 4 stars for Elevance health contracts
• Serve as the subject matter expert evaluating and implementing clinical quality and cost of care programs.
• Manages predictive clinical and economic rule sets used in the pharmacy member and provider communications.
• Supports sales and account management and Elevance Health plans in achieving 4 star for individual contracts
• Collaborates with the Care Management, HEDIS, Clinical Pharmacy Care Center to improve medication compliance and achieve corporate goals
• Provides Request for Proposal (RFP) support and assists with business growth and client retention.
• Manages budget and increases clinical product revenue.
• Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Minimum Requirements:

Requires a PharmD, RPh or MPh and minimum of 5 years of managed care experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted Pharmacist license in applicable state(s) required. Requires BS in Pharmacy.  

Preferred Skills, Capabilities, and Experience:

• Demonstrated expertise in CMS Medicare Star Ratings measures, methodology, and strategies to improve quality and performance outcomes, including experience achieving 4-Star performance, strongly preferred.
• Demonstrated experience establishing ongoing performance monitoring processes, conducting root cause analysis, identifying performance gaps and improvement opportunities, and implementing data-driven interventions to enhance quality, operational, and business outcomes, strongly preferred.
• Demonstrated ability to manage vendor relationships, oversee contractual performance, drive accountability, and ensure successful execution of programs through quality assurance processes, closed-loop reviews, performance validation, and ongoing program optimization, strongly preferred.
• Strong proficiency in Excel, including data analysis, dashboard development, reporting, trend analysis, performance tracking, and the ability to translate data into actionable recommendations, identify trends, measure program effectiveness, and support business decision-making, strongly preferred.
• MBA preferred.
• Demonstrated ability to influence and collaborate effectively across Quality, Pharmacy, Operations, Analytics, Clinical, and Executive Leadership teams, combined with strong communication, stakeholder management, accountability, flexibility, and problem-solving skills, strongly preferred.
• Specific knowledge of OIG, ERISA, HIPAA and the regulatory environment, DSM / HEDIS / Quality Improvement / Clinical Interventions program development and oversight strongly preferred.
• Demonstrated program management experience leading complex, cross-functional initiatives, driving execution, managing competing priorities, and ensuring successful delivery of strategic objectives while achieving key business and quality outcomes, strongly preferred.

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Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.