ACA Clinical Pharmacist PCHP

Parkland Health

1d•Hybrid

About The Position

Responsible for managing pharmacy operations and clinical activities for Parkland Community Health Plan (PCHP), including oversight of the contracted pharmacy benefit manager. Develops, implements, and manages clinical pharmacy initiatives for PCHP members, including Marketplace/ACA members, to support optimal drug treatment outcomes and minimize costs. The role includes pharmacy operations, clinical review and program management, reporting and data analysis, regulatory compliance, fiscal management, and collaboration with internal and external stakeholders. Strong candidates will have experience working within a health plan or managed care organization.

Requirements

Doctor of Pharmacy degree (Pharm D).
Six years of experience as a practicing pharmacist in a healthcare, health plan, or managed care organization.
Current and unrestricted pharmacist license in the State of Texas.
Excellent verbal and written communication skills, including the ability to communicate professionally across disciplines and explain complex information in understandable terms.
Ability to coach and influence for results.
Strong interpersonal and conflict-resolution skills and ability to establish and maintain effective working relationships with diverse groups.
Strategic thinking and long-range planning skills, including ability to lead major 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, including ability to manage multiple demands and rapidly changing priorities.
Advanced analytical and problem-solving skills.
Knowledge of ACA/Marketplace plans, CMS, Texas Medicaid (STAR, STAR Kids/CHIP), NCQA, the Uniform Managed Care Contract, Uniform Managed Care Manual, Texas Department of Insurance, State Board of Pharmacy, DEA, FDA, and Vendor Drug Programs.
Sound business acumen.
Proficiency with Microsoft Office and computer skills.

Nice To Haves

Completion of a Pharm D. postgraduate residency program.
Three years of experience with utilization management in a healthcare delivery setting.
Experience with commercial or Marketplace products.
Project management or Six Sigma certification.
Experience working within a health plan or managed care organization.

Responsibilities

Support leadership and the provider network department with member care coordination and pharmacy benefit management matters.
Provide vendor oversight and manage the pharmacy benefit manager contract for ACA business.
Oversee development and maintenance of the Drug Formulary, Prior Authorization list, standards, and clinical policies for the ACA/Marketplace line of business.
Oversee pharmacy services, review guidelines, and implement policies and procedures to ensure timely care and appropriate services.
Identify strategies to optimize targeted members’ medication regimens and improve outcomes while lowering pharmacy and medical costs.
Assist with pharmacy-related health promotion and chronic disease management programs supporting population health management and health plan goals.
Assist with writing and updating policies and procedures, and developing, implementing, and monitoring annual pharmacy department goals and objectives.
Serve as a clinical pharmacy subject matter expert and support strategies for cost-effective medication utilization, adherence, clinical quality, formulary compliance, and regulatory standards.
Lead pharmacy Fraud, Waste, and Abuse evaluations, pharmacy quality management and improvement activities, and drug-related disease management and care management efforts.
Perform audits of vendors and delegates as needed to maintain regulatory compliance and accreditation readiness.
Develop, implement, and manage clinical pharmacy initiatives for health plan members to support optimal drug treatment outcomes and minimize costs.
Create and manage clinical projects and pharmacy initiatives, using data to measure outcomes and interventions.
Manage provider-specific report cards and communicate with prescribers and members about strategies to optimize treatment outcomes as appropriate.
Review prior authorizations for high-cost medications under medical and pharmacy benefits using clinical criteria, ensuring consistent and accurate application and compliant timeliness.
Provide clinical support to the Appeals department.
Perform comprehensive medication regimen reviews for members, including those treated with targeted specialty pharmaceuticals and other directed drug classes.
Assess member adherence, medication appropriateness against current clinical criteria and guidelines, and achievement of treatment goals.
Develop clinical and administrative reports, dashboards, written communications, and other deliverables to track, monitor, and communicate the effectiveness of PCHP’s clinical pharmacy program.
Develop and analyze periodic pharmacy utilization reports, provide clinical and pharmacoeconomic data to administration and senior staff, and identify cost-saving opportunities and outcome-oriented recommendations.
Collaborate with PCHP partners, the pharmacy benefit manager, physicians, providers, contracted vendors, and HHSC representatives to manage pharmacy benefit utilization in accordance with treatment standards, contractual requirements, regulations, and accreditation standards.
Coordinate pharmacy regulatory readiness and compliance, including preparation for external monitoring surveys and reviews.
Ensure accurate and timely submission of regulatory reports; develop compliance processes; and ensure operations comply with applicable requirements.
Collaborate to validate and sustain regulatory and accreditation compliance; conduct routine compliance audits, identify gaps, and implement remediation plans.
Work with leadership and/or PCHP Compliance to investigate concerns or alleged violations and take corrective action as necessary.
Respond accurately and promptly to information requests from regulatory agencies and accrediting bodies.
Manage the financial performance of assigned areas, promote operational efficiency, monitor the approved budget, and implement written action plans to address variances and meet budget targets.
Consider operational outcomes and financial implications when recommending new or modified programs.
Support a culturally welcoming, inclusive, collaborative, and engaged work environment.
Collaborate with internal and external stakeholder teams to improve pharmacy processes for the ACA line of business.
Support and educate operational teams about pharmacy matters related to the ACA line of business; cross-cover Medicaid pharmacy activities as needed.
Act with integrity and ethical standards, adhere to Parkland’s mission, vision, values, policies, procedures, and guidelines, and maintain confidentiality.
Complete assigned training, self-appraisal, and annual health requirements on time; attend required meetings and town halls; and adhere to hybrid work schedule requirements.
Recognize and communicate ethical and legal concerns through established channels.
Complete work, projects, and assignments independently and on time, provide timely responses to information requests, and perform other reasonably related work as requested.
Analyze job design, work processes, and workflows and implement changes to improve effectiveness, productivity, and efficiency in support of department and Parkland goals.
Stay current with developments and trends in the field through professional learning and participation, and integrate knowledge into work practices.
Maintain knowledge of applicable rules, regulations, policies, laws, and guidelines; develop internal controls that promote compliance; and seek advice or guidance as needed.