The posting
Special Note: Strong candidates will have experience working within a health plan or managed care organization.
PRIMARY PURPOSE
Responsible for managing pharmacy operations and clinical activities for Parkland Community Health Plan (PCHP) including the contracted pharmacy benefit manager, ensuring the development, implementation, and management of clinical pharmacy initiatives for PCHP, including Marketplace/ACA members to ensure optimal drug treatment outcomes and minimize costs.
MINIMUM SPECIFICATIONS
Education
- Doctor of Pharmacy degree (Pharm D) required.
Experience
- Six (6) years of experience as a practicing pharmacist in a healthcare, Health plan or managed care organization required.
- Completion of a Pharm D. post graduate residency program preferred.
- Three (3) years of experience with utilization management in a health care delivery setting preferred.
- Experience with commercial or Marketplace products is preferred.
Equivalent Education and/or Experience
- None.
Certification/Registration/Licensure
- Current and unrestricted license as a pharmacist in the State of Texas.
- Project management or Six Sigma certification preferred.
Required Tests for Placement
- None.
Skills or Special Abilities
- Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines and with a variety of constituents as well as the ability to articulate complex information in understandable terms.
- Demonstrated ability to coach and influence for results.
- Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships with diverse groups across and beyond the organization.
- Strategic thinking and long-range planning skills with the ability to lead major organizational initiatives, accomplish results, and achieve measurable outcomes or goals.
- Ability to work in challenging situations involving competing interests, and high level-interdisciplinary groups.
- Excellent time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
- Advanced analytical and problem-solving skills.
- Knowledge of programs, regulations, and standards for ACA/Marketplace plans, CMS, Texas Medicaid (STAR, STAR Kids/CHIP) program, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, Uniform Managed Care Manual, Texas Department of Insurance (TDI) State Board of Pharmacy, Drug Enforcement Agency (DEA), Food & Drug Administration (FDA), and Vendor Drug Programs (VDP).
- Sound business acumen.
- Proficient Microsoft Office and computer skills.
Responsibilities
Pharmacy Operations
- Supports leadership and the provider network department to facilitate member care coordination and to address other matters that may arise related to pharmacy benefit management.
- Provides vendor oversight and manages the pharmacy benefit manager contract for ACA business.
- Oversees the development and maintenance of the Drug Formulary and Prior Authorization list, standards and clinical policies for the ACA/Marketplace line of business.
- Oversees pharmacy services to include review of guidelines and implementation of new policies and procedures to ensure members receive timely care and appropriate medical services.
- Identifies opportunities and strategies to work with members, care coordination team and prescribers to optimize targeted members' medication regimens to improve patient outcomes and lower pharmacy / medical costs.
- Assist with pharmacy related health promotion and chronic disease management programs in support of population health management and health plan goals.
- Assists with writing and updating policies and procedures, as needed. Assists with the development, implementation, and monitoring of annual goals and objectives for the pharmacy department that support the missions and objectives of the PHHS , PCHP and the pharmacy department.
- Provides expertise as a clinical pharmacy subject matter expert and supports the health plan in pharmacy related strategies that promote cost-effective medication utilization, medication adherence, clinical quality, adherence to the formulary, and regulatory standards.
- Leads PCHP’s auditing in Pharmacy Fraud, Waste, and Abuse evaluations, Pharmacy quality management and improvement activities, and drug related disease management and care management efforts.
- Perform Audits for Vendors/Delegates as needed to maintain regulatory compliance and accreditation readiness.
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Clinical Activities
- Responsible for development, implementation, and management of clinical pharmacy initiatives for health plan members to ensure optimal drug treatment outcomes and minimize costs.
- Creates and manages clinical projects and pharmacy initiatives for the program. Uses data to measure quantifiable outcomes and interventions.
- Manages provider specific report cards and communicates with prescribers and members about strategies to optimize drug treatment outcomes as appropriate.
- Completes prior authorization review of high-cost medications for medical and pharmacy benefit based on clinical criteria. Ensures consistent and accurate application of clinical criteria while maintaining compliant timeliness standards.
- Provides the Appeals department with clinical support.
- Performs comprehensive medication regimen review for members, members treated with targeted specialty pharmaceuticals and other drug classes as directed.
- Assess member compliance to prescribed regimens, appropriateness of prescribed medications based on current clinical criteria / guidelines and attainment of treatment goals.
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Reporting and Data Analysis
- Develops clinical and administrative reports/dashboards, written communications to members and providers, and other deliverables as assigned to track, monitor, and communicate effectiveness of PCHP's clinical pharmacy program.
- Develops and analyzes periodic pharmacy utilization reports to provide clinical and/or pharmacoeconomic data to administration and senior staff to ensure pharmacy goals are met for the overall quality of care and specifically for Care Management programs. Identifies areas for cost saving programs and outcomes-oriented recommendations when applicable.
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Regulatory
- Works collaboratively with PCHP’s internal and external partners, pharmacy benefit manager, physicians, healthcare providers, contracted vendors and HHSC’s representatives to manage the pharmacy benefit utilization in accordance with current treatment standards, contractual requirements as well as regulatory requirements and accreditation standards.
- Coordinates Pharmacy related regulatory readiness and compliance for PCHP. This includes working with Department leadership in Health Services, Quality Member Relations, Third Party Administrators (TPA) and Pharmacy vendor. Prepares Pharmacy for various external monitoring regulatory surveys and reviews including but not limited to the following relevant bodies: the State Board of Pharmacy, Drug Enforcement Agency (DEA), Food and Drug Administration (FDA), Office of Inspector General (OIG), Texas Department of Insurance (TDI), Health and Human Services Commission (HHSC), Centers for Medicare & Medicaid Services (CMS), National Committee of Quality Assurance (NCQA), and Vendor Drug Program (VDP).
- Ensure the accuracy and timely submission of regulatory reports.
- Develop processes to maintain compliance with regulatory agencies and accrediting bodies. Ensures operations are carried out in compliance with these regulations.
- Works collaboratively with others to validate and sustain compliance with regulatory and accreditation standards.
- Conducts routine compliance audits identifying gaps and implementing remediation plans as necessary.
- Works collaboratively with leadership and/or PCHP Compliance to investigate and respond to matters of concern or alleged violations taking corrective action as necessary.
- Provides timely and accurate responses to requests for information from regulatory agencies and accrediting bodies.
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Fiscal Management and Operating Budget
- Operationally responsible for the financial performance of assigned area(s).
- Promote activities to achieve operational efficiency.
- Manage the approved budget through frequent and regular monitoring. Implement written action plans to address variances adjusting strategies as necessary to meet budgetary targets.
- Consider operational outcomes and financial implications when making recommendations to implement new programs or modify current programs.
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Operational Collaboration
- Support a culturally welcoming, inclusive, collaborative, and highly engaged work environment where everyone feels empowered to bring their full, authentic selves to work.
- Collaborates across internal and external stakeholder teams to drive pharmacy process excellence for the ACA line of business.
- Support and educate operational teams about Pharmacy related matters pertaining to ACA line of business.
- Cross Covers Medicaid Pharmacy activities as needed.
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Professional Accountability
- Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
- Adheres to organizational policies, procedures, and guidelines.
- Completes assigned training, self-appraisal, and annual health requirements timely.
- Adheres to hybrid work schedule requirements.
- Attends required meetings and town halls.
- Recognizes and communicate ethical and legal concerns through the established channels of communication.
- Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
- Maintains confidentiality at all times.
- Performs other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.
Job Accountabilities
- Identifies and analyzes the design of jobs, work processes, work flows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of the department and Parkland.
- Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
- Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.
