This job is directly responsible for the value creation, impact and cost control, and fiscal/ROI targets as set by the Organization. This includes revenue stream outcomes and engagement of primary care providers (PCP) and facilities enrolled in the Organization’s value based reimbursement programs, clinical care models, and continuous improvement models. The incumbent applies subject matter expertise in clinical pharmacy, pharmacy formulary, pharmacy benefit design, pharmacy policy, medical drug policy, therapeutic alternatives, medication adherence strategies, Medication Therapy Management, utilization management, immunizations, specialty pharmacy, Medicare Stars, and Medicaid HEDIS to strategies designed to promote the Organization’s value based reimbursement PCP and facility programs. The incumbent acts as a highly skilled subject matter expert (SME) in the Organization's value based reimbursement PCP and facility programs providing strategic, hands-on, office based support to PCPs and facilities for analysis of performance in quality, cost, and utilization scores, identifies opportunities for improvement in value creation, cost control and utilization, performance, and develops strategic plans in collaboration with PCPs and facilities and the interdepartmental teams for transformation of workflows resulting in outstanding performance in the Organization's value based reimbursement PCP and facility program(s), ensuring that ROI targets as set by the Organization are met or exceeded. Further, in a matrix management environment, the incumbent collaborative works with other functions in the provider area, data analytics, pharmacy team, and key internal/external stakeholders to provide the most appropriate support to the PCP's based upon data analysis and dashboard reports.
- Serve as the Clinical Pharmacy SME and support broader CTC team in pharmacy related report interpretation and assist in the development of strategies for PCPs and facilities that promote generic substitution, medication adherence, success in pharmacy related Stars and HEDIS measures, completion of comprehensive medication reviews, adherence to pharmacy and medical drug policy, and adherence to the Organization’s formulary.
- Provide office based, hands-on consultative workflow transformation and training/education services to PCPs and facilities enrolled in the Organization's value based reimbursement programs and clinical evidence based guidelines. Assess the needs of each individual PCP practice and use a combination of on-site individual office-based, entity-level-based, video conference, teleconference and electronic mail interactions to drive engagement and exemplary value creation, impact and cost control, and ROI/fiscal outcomes as set by the Organization for PCP and facility programs.
- Assess data for the highest ROI opportunities in PCP performance, and implement strategic plans to meet identified program targets across all of the Organization's value based programs for both the commercial and government business (ACA, Medicare STARS, Medicaid HEDIS, risk revenue).
- Function as the Organization's representative SME in value based reimbursement programs, pharmacy, and data analysis. This includes creation and presentation of program results to both internal and external audiences, including practice and entity meetings.
- Analyze and interpret PCP and facility value based reimbursement reports in the areas of National Quality Standards like NCQA, HEDIS, NQF, PQRS etc., and cost and utilization and develop strategic plans to meet PCP program targets to create value, impact and cost savings, as well as meeting the ROI as identified by the Organization. Provide feedback to and collaborate with data analytics to ensure PCP and facility reports are accurate and provide meaningful, actionable data to PCPs and facilities.
- Independently and autonomously manage PCP and facility caseloads, projects, meetings, deliverables, resources etc. for individualized strategic plans to transform PCP and facility practices enrolled in value based reimbursement program(s) using innovative continuous improvement methodologies. This includes cross training in all of the Organization's value based reimbursement programs to lend support as needed/defined by market outcomes.
- Serve as the clinical SME for PCP value based reimbursement programs, Medicare STARS, Medicaid HEDIS, for both the Organization's internal and external key stake holders. In a matrix management environment, works collaboratively with the interdepartmental team to provide the most comprehensive support to PCPs and facilities for full practice transformation.
- Function in a matrixed role supporting the development and strategic integration of clinical care models for chronic conditions and in collaboration with departments across the enterprise.
- Other duties as assigned.
- Bachelor's Degree in Pharmacy
- 5 - 7 years in Pharmacy
- 3 - 5 years in a Clinical Practice
- Analytical Skills
- Medicare Experience
- Presentation Delivery
- Managed Care
- Master's Degree in Health Administration or Business
- Doctorate Degree in Pharmacy (PharmD)
- 5 - 7 years in Medicare - OR 5 - 7 years in Managed Care Support - OR 3 - 5 years in Quality Improvement - OR 3 - 5 years in Care Management - OR 3 - 5 years in Utilization Review - OR 3 - 5 years in the Health Insurance Industry
- Board Certified Pharmacotherapy Specialist
- Board Certified Ambulatory Care Pharmacist
- Board Certified Geriatric Pharmacist
Care Planning Experience
- Continuous Improvement Experience
- Utilization Management Experience
- Healthcare Management Experience
- Utilization Review Experience