Managed Care Pharmacist – Managed Care, PBM

Job not on LinkedIn

🕒 August 30

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

💊 Pharmacist

👻 Ghost score 32%

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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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.

📋 Description

• Supports all aspects of Pharmacy Benefit Manager (PBM) implementation • Brokers communication among clients, key stakeholders, and the PBM on issue resolution • Ensures execution of desired plan benefit design • Educates clients and key stakeholders on pharmacy benefits • Assists in optimizing clinical outcomes while reducing pharmacy spend • Supports quality assurance activities for utilization management reviews • Develops and implements clinical and quality program design for pharmacy benefits • Evaluates clinical and performance metric reporting and medication utilization • Oversees formulary administration and pharmacy benefit development • Profiles cost and utilization plan data and supports provider relations • Serves as a consultant between Peak lines of business and clients • Reports pharmacy measure performance and gap closure to health plan leadership • Develops, implements, tracks, reports, and evaluates PBM clinical program initiatives • Identifies cost-saving, quality improvement, and clinical strategies • Collaborates with internal stakeholders, external clients, and the PBM • Performs data-driven analyses of clinical program outcomes • 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, committee, and cross-functional workgroup meetings • Provides guidance to pharmacy services staff • Manages vendor relationships related to Part D Stars measure performance • Ensures regulatory compliance and reporting • Monitors issues for processing improvement and education opportunities • Monitors PBM adherence to CMS metrics and key performance indicators • Reconciles and reports Drug Management Program data • Resolves clinical eligibility flag discrepancies from PBM PDE rejections • Supports pharmacy and formulary directory documentation using CMS guidance • Coordinates 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 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 preferred • Experience with regulatory and accreditation standards • Extensive working knowledge of Microsoft Office applications (Excel and Access) • Experience with audits • 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 • Ability to work in a fast-paced and rapidly changing environment