Clinical Pharmacy Program Director - Medicare Star Program Management

Elevance Health•Atlanta, GA

8d•Hybrid

About The Position

The Clinical Pharmacy Program Director is responsible for leading, developing, and implementing Medicare CMS Star pharmaceutical management initiatives and processes that impact health care quality, cost of care, and outcomes for all aspects of the retail and medical benefit. In addition, also oversees the pharmacy CMS Star Portfolio including enterprise and contract level strategy execution and performance while maintaining compliance with all related regulations and guidance.

Requirements

Requires a PharmD and minimum of 5 years of health plan managed care experience which includes minimum of 3 years of management experience, preferably in managed care and minimum of 2 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current unrestricted license to practice pharmacy as a RPh in applicable state(s) required.

Nice To Haves

MBA preferred.
Demonstrated expertise in CMS Medicare Star Ratings measures, methodology, and strategies to improve quality and performance outcomes, including experience achieving 4-Star performance, along with experience establishing ongoing performance monitoring processes, conducting root cause analysis, identifying performance gaps, uncovering improvement opportunities, and implementing data-driven interventions to enhance quality, operational, and business outcomes, is strongly preferred.
Demonstrated ability to manage vendor relationships, oversee contractual performance, drive accountability, and ensure successful execution of programs through quality assurance processes, closed-loop reviews, performance validation, and ongoing program optimization is strongly preferred.
Strong proficiency in Excel, including data analysis, dashboard development, reporting, trend analysis, performance tracking, and the ability to translate data into actionable recommendations, identify trends, measure program effectiveness, and support business decision-making is strongly preferred.
Demonstrated program management experience leading complex, cross-functional initiatives, driving execution, managing competing priorities, and ensuring successful delivery of strategic objectives while achieving key business and quality outcomes is strongly preferred.
Demonstrated ability to influence and collaborate effectively across Quality, Pharmacy, Operations, Analytics, Clinical, and Executive Leadership teams, combined with strong communication, stakeholder management, accountability, flexibility, and problem-solving skills, strongly preferred.

Responsibilities

Develops and implements Medicare CMS Star initiatives/programs and operation procedures to achieve quality, efficiency and cost of care goals.
Serves as the subject matter expert for CMS Star program implementations.
Establishes processes to monitor compliance and quality of care issues for CMS Star programs.
Addresses and resolves program and Medicare contract performance to achieve target.
Supports sales and account management for Elevance health plans.
Builds effective relationships with internal and external stakeholders.
Interfaces with claim and medical management systems experts to assist in the early identification of high-risk pharmacy claims.