Manager, Pharmacy

1 month ago

Orange, United States Prospect Medical Holdings Full time
Job Description

The main responsibilities of the Pharmacy Manager include: 1) leading the pharmacy referral team to ensure compliance with federal, state, health plan and IPA guidelines; 2) providing support and engaging in initiatives and processes implemented to manage specialty pharmacy costs; 3) implementing and monitoring for value-based contracts to meet pharmacy cost targets; 4) oversight on pharmaceutical rebate submission & monitoring processes, health plan cap deductions, and duplicate claims.

Responsibilities

To perform this job successfully, an individual must be able to perform the job description satisfactorily. This job description reflects management's assignment of essential functions, it does not prescribe or restrict the tasks that may be assigned. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

Manage the pharmacy referral team to ensure compliance with federal/state/health plan/IPA guidelines, educate staff on clinical and administrative updates and implement utilization management strategies through ongoing assessments of new drugs and data analyses. Implement operational changes through staff education and interdepartmental collaboration (e.g., process improvement, new clients, onboarding of new health plans, capitated specialist groups). Create goals, metrics as well as monitoring tools for the staff and assigned processes, and provide monthly pharmacy reports, lead team meetings.

Conduct monthly assessments of pharmacy data by region and for value-based contracts to identify targeted drugs and prescribers to promote evidence-based cost-effective utilization. Implement clinical interventions and provide monthly summary reports.

Oversee and monitor the process of submitting and auditing rebate reports, health plan cap deduction files, duplicate claims reports, and MTM payments. Dispute inappropriate cap deducted claims with health plans by coordinating with all internal stakeholders. Lead ongoing interdepartmental meetings for cap deductions.

Provide assistance and participate in state and health plan audits. Assess staffing bandwidth to ensure compliance with turn-around-time and other UM-related requirements. Provide support for member appeals and grievances. Review leakage reports for capitated specialist groups

Process daily referrals and complete ad hoc projects.
  • Microsoft Excel, Word, PowerPoint
  • Good written and verbal communication skills
Qualifications
  • Must hold an active pharmacist license for CA
  • Management experience
  • Prior authorization experience
  • Experience and knowledge for injectables and infusion
  • Health plan pharmacy vs. medical benefits
  • Active pharmacist license for AZ and TX.

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