Managed Care Pharmacist – Managed Care/PBM

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

👻 Ghost score 10%

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Peak Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.

📋 Description

• Serve as a consultant between Peak lines of business and clients to support pharmacy benefit management operations • Provide reporting to health plan leadership on pharmacy-measure performance and gap closure • Develop and implement clinical quality programs addressing industry and regulatory gaps in care • Design, implement, track, report, and evaluate PBM clinical program initiatives • Identify strategies to impact plan quality and clinical goals and outcomes • Collaborate with internal stakeholders, external clients, and the PBM on cost-saving and quality-improvement initiatives • Assess clinical program outcomes using data-driven analyses and identify improvement opportunities • Work with clinical, quality, and data analytics teams to identify and incorporate data needs and perform analysis • Liaise with the PBM and assist the Manager of Pharmacy Services with oversight of clinical and quality programs • Conduct quality assurance analyses of utilization management reviews • Participate in client, external partner, clinical committee, and cross-functional workgroup meetings • Provide guidance to pharmacy services staff • Assist in developing cost-saving strategies while optimizing clinical outcomes • Manage vendor relationships related to Part D Stars measure performance • Ensure compliance with regulatory guidelines and reporting • Monitor issues for processing improvement or education opportunities • Attend external vendor meetings to communicate pharmacy goals • Monitor PBM adherence to CMS metrics and key performance indicators for Medicare • Reconcile and report Drug Management Program data addressing overutilization • Resolve clinical eligibility flag discrepancies from PBM PDE rejections • Support pharmacy and formulary directory documents using CMS guidance • Liaise between internal departments and PBM Client Account Executives to support enrollees and resolve issues

🎯 Requirements

• Current and unrestricted license to practice pharmacy issued by state of residence • Three (3) years of experience as a pharmacist in a managed care setting • Experience with pharmacy formulary strategy and design (preferred) • Specific knowledge of CMS regulations, HIPAA and regulatory environment (preferred) • Part D Clinical Interventions program development and implementation experience (preferred) • Board Certification in managed care pharmacy and/or managed care program certificate (preferred) • Ability to stand and walk short distances for eight or more hours • Frequent bending, stooping or stretching • Ability to lift 30 pounds and push 50 pounds • Ability to work under stressful working conditions • Ability to handle and maintain confidential information • Ability to work independently or cooperatively as a team member • Experience with regulatory and accreditation standards • Ability to work in a fast-paced and rapidly changing environment • Extensive working knowledge of Microsoft Office applications, including Excel and Access • Experience with audits

🏖️ Benefits

• Full-time position • Exempt status • 40 scheduled weekly hours • Reasonable accommodations may be made for individuals with disabilities • Some travel to offsite meetings may be required