Managed Care Pharmacist – Managed Care/PBM

🕒 August 30

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

👻 Ghost score 33%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Serves as a consultant between Peak lines of business and clients to support pharmacy benefit management operations • Provides reporting to health plan leadership on pharmacy measure performance and gap closure • Develops and implements clinical quality programs addressing industry and regulatory gaps in care • Designs, implements, tracks, reports, and evaluates PBM clinical program initiatives • Identifies strategies to impact plan quality and clinical goals and outcomes • Collaborates with internal stakeholders, external clients, and the PBM on cost-saving and quality improvement initiatives • Assesses clinical program outcomes using data-driven analyses and identifies improvement opportunities • Works with clinical, quality, and data analytics teams to identify and incorporate data needs • Serves as liaison to the PBM and assists with oversight of clinical and quality programs • Conducts quality assurance analyses of utilization management reviews • Participates in client, partner, clinical committee, and cross-functional workgroup meetings • Provides guidance to pharmacy services staff as needed • Assists in developing cost-saving strategies while optimizing clinical outcomes • Manages vendor relationships related to Part D Stars measure performance • Ensures regulatory compliance and reporting • Monitors issues for processing improvement or education opportunities • Attends external vendor meetings • Monitors PBM adherence to CMS metrics and key performance indicators for Medicare • Reconciles and reports Drug Management Program data • Resolves clinical eligibility flag discrepancies from PBM PDE rejections • Supports pharmacy and formulary directory documents using CMS guidance • Liaises between internal departments and PBM Client Account Executives for enrollee care and issue resolution

🎯 Requirements

• Must possess 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 regulatory and accreditation standards • Extensive working knowledge of Microsoft Office applications (Excel and Access) • Experience with audits • Ability to work under stressful working conditions • Ability to handle and maintain confidential information • Ability to work independently or cooperatively as a team member • Ability to work in a fast-paced and rapidly changing environment • 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 • Preferred: Board Certification in managed care pharmacy and/or managed care program certificate • Preferred: Experience in 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