Dir- Clinical Pharmacy Program
2 months ago
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
This position requires work and residency in Arizona.
Purpose of the job
This position exercises broad clinical, strategic and operational oversight for planning, organizing and directing all aspects of Blue Cross® Blue Shield® of Arizona Medicare clinical pharmacy programs including but not limited to all Medicare Part D, Part B and stand-alone prescription drug plan programs and compliance requirements, formulary design and maintenance, and pharmacy utilization and quality management. Acts as primary clinical, operations and compliance pharmacy liaison with the designated pharmacy benefits manager (PBM).
REQUIRED QUALIFICATIONS
Required Work Experience
- 7 years' experience in a Medicare Advantage environment and two years' experience in a PBM environment
- 3 years of progressively responsible administrative leadership experience in a healthcare related setting.
- Doctor of Pharmacy (PharmD) degree or BS Pharmacy with extensive experience in Medicare managed care
- Active, current and unrestricted State of Arizona (a state in the United States) pharmacist license
- N/A
Preferred Work Experience
- Additional geriatric fellowship training and / or direct hands on pharmacy benefits management experience.
- Additional related education and/or experience preferred.
- Directs the planning and implementation of the BCBSAZ Medicare Clinical Pharmacy and Part B and Part D Services functions.
- Provides operational support of the Part B and Part D programs including selection of drugs for utilization management, interface with claims processing systems, audits and ensuring CMS compliance.
- Ensures initial and continuing competency of staff under their respective responsibilities. Initiates recruitment, selection, and provides for training, development, coaching, and motivation of employees. Further, maintains and encourages a positive working environment through a variety of communication systems, positive recognition, intervention and practices resignation recovery.
- Provides strategic direction, operational oversight, and financial impact analysis for all Medicare clinical pharmacy programs and all Medicare Part B and Part D mandated programs.
- Ensures compliance with all CMS, Medicare Part B and Part D and Arizona Department of Insurance requirements for pharmacy services, pharmacy benefits, P & T committee, , quality assurance and member safety, medication therapy management programs, coordination with Chronic Care Improvement Programs, pharmacy utilization management (i.e. exceptions, prior authorizations, step therapies, etc.), and supports grievances and appeals.
- Serve as owner of and liaison with designated PBM relationship to ensure compliance and operational efficiency related to clinical oversight, pharmacy claims processing, claims reversals, Troop tracking and reporting, coordination of benefits, EOB determinations and reporting, low-income subsidy, Reinsurance calculations, Drug Claims data encountering, pharmacy access monitoring, home infusion pharmacy monitoring, long term care pharmacy monitoring, ITU pharmacy monitoring, Part B and Part D reporting. Leads joint operations with the designated PBM to facilitate all Part B and Part D implementation issues, and ongoing operational issues.
- Develop and analyze efficiency and quality metrics and improves performance on a continuous basis.
- Participates in the financial and services evaluation of PBM vendors through requests for proposal and market checks and PBM prescription claims pricing audits
- Responsible for CMS regulations and compliance related to clinical requirements.
- Acts as subject expert in all Medicare clinical pharmacy areas and provides ongoing education to internal partners, members, and Network physicians.
- Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers with an excellent service experience by consistently demonstrating core and leader behaviors each and every day.
- Responsible for FEP pharmacy services including clinical and performance improvement programs
- Responsible for managing budgets and financial tracking and analysis including Stars, Part B and Part D and other clinical programs.
- Responsible for formulary development and maintenance including analysis of potential member disruption
- Responsible for Part D bid submission related to clinical submissions such as Medication Therapy Management Programs and Formulary submissions
- Responsible for Stars vendor relationship management and clinical and operational oversight related to pharmacy programs
- Responsible for value-based provider relationship management
- The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
- Perform all other duties as assigned
Required Job Skills
- N/A
- Analytical and critical thinking skills are required to integrate and interpret data from diverse sources.
- Able to integrate information to establish business-based priorities, decisions and budgets.
- Ability to develop strong relationships with suppliers and customers and to effectively communicate with employees, medical staff, and management staff.
- Strong interpersonal skills are required.
- Able to communicate effectively at all levels and demonstrate leadership ability and group facilitation skills.
- N/A
Preferred Job Skills
- N/A
- N/A
- N/A
Our Commitment
AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
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