Job Profile
JOB SUMMARY
The Clinical Pharmacy Program Manager provides highly specialized integrated clinical pharmacy services to the health plan. This position is responsible for managing both clinical and operational functions for pharmacy benefit administration for the assigned line of business. The Clinical Pharmacy Program Manager will be responsible for supervising clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Review medical and pharmacy benefit claims data for trends and outliers to identify opportunities to enhance medication UM strategies on high-cost drugs, formulary strategies, and Fraud, Waste, Abuse (FWA) reporting, lead Complex Medication Management program initiatives
Perform utilization management review of drug requests as assigned, including but not limited to prior authorization review, appeals, non-formulary exception and override requests
Analyze utilization and prior authorization data to identify drug utilization trends and cost-savings opportunities
Conduct oversight over prior authorization criteria and delegated utilization management functions performed by PBM
Serve as clinical resource supporting Care Management, Service Coordination, and Utilization Management functions on medication-related projects and inquiries
Manage the Medication Therapy Management (MTM) program
Supervise clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned
Actively contributes to achievement of departmental goals, including specific departmental process improvement plans, and other duties as assigned.
Review medical and pharmacy benefit claims data for trends and outliers to identify opportunities to enhance medication UM strategies on high-cost drugs, formulary strategies, and Fraud, Waste, Abuse (FWA) reporting, lead Complex Medication Management program initiatives
Perform utilization management review of drug requests as assigned, including but not limited to prior authorization review, appeals, non-formulary exception and override requests
Analyze utilization and prior authorization data to identify drug utilization trends and cost-savings opportunities
Conduct oversight over prior authorization criteria and delegated utilization management functions performed by PBM
Serve as clinical resource supporting Care Management, Service Coordination, and Utilization Management functions on medication-related projects and inquiries
Manage the Medication Therapy Management (MTM) program
Supervise clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned
Actively contributes to achievement of departmental goals, including specific departmental process improvement plans, and other duties as assigned.
Reports to Position Title: Director, Pharmacy Analytics-CHC
Employees Supervised Titles: Managed Care Clinical Pharmacist, Pharmacy Program Specialist
QUALIFICATIONS:
Education/Specialized Training/Licensure: Bachelor's degree in pharmacy if candidate does not have a Doctor of Pharmacy degree. (Bachelor's degree is not required if candidate has Doctor of Pharmacy degree.) required.
Active license as a pharmacist in Texas required; or will have Texas pharmacist license prior to start date required.
Doctor of Pharmacy degree preferred.
Work Experience (Years and Area): Minimum 5 years of applicable managed care pharmacy experience as a registered pharmacist;
or at least 4 years of relevant pharmacy experience AND completion of advanced training (i.e., completion of PGY1 managed care pharmacy residency, master, or doctorate degree in a quantitative discipline such as finance, accounting, business administration, or informatics)
Strong experience with drug utilization management required.
Minimum 4 years experience in Medicare, Medicaid, and/or Marketplace with a Health Plan or PBM required Experience with SQL preferred
Strong experience with medication management programs preferred
Work Experience (Years and Area): Minimum 5 years of applicable managed care pharmacy experience as a registered pharmacist;
or at least 4 years of relevant pharmacy experience AND completion of advanced training (i.e., completion of PGY1 managed care pharmacy residency, master, or doctorate degree in a quantitative discipline such as finance, accounting, business administration, or informatics)
Strong experience with drug utilization management required.
Minimum 4 years experience in Medicare, Medicaid, and/or Marketplace with a Health Plan or PBM required
Experience with SQL preferred
Strong experience with medication management programs preferred
Software Proficiencies: Microsoft Office (Word, Excel, Outlook, Power Point)
Experience with advanced Excel required
Visio preferred.
Job Family/Job Title Competencies
Problem Analysis
Results Oriented
Attention to Detail
Leadership
List any additional competencies not indicated above:
Exceptional Verbal and Written Communication
Managing Conflicts
Customer Oriented
Ability to work independently with minimal supervision
Taking initiative
INTERPERSONAL SKILLS
Ability to explain and communicate complex ideas with a diverse population.
