Director, Pharmacy Clinical Strategy(Preferred Experience in Medical Drug Management Strategy)

CareSource • Dayton, OH

5d • $135,600 - $237,400 • Onsite

About The Position

The Director, Pharmacy Clinical Strategy leads the strategic development of formulary management best practices & industry-leading, market-competitive formulary and medical drug strategies across all CareSource lines of business and markets. This role ensures the efficient operational management of formulary and medical drug management and clinical policy/criteria development teams, focusing on execution, outcomes, continual improvement, and performance enhancement. The Director oversees the monitoring of and educates stakeholders on the drug development pipeline and strategies for managing new and existing drugs. They also ensure business partner accountability for the accurate and timely implementation and testing of benefit and formulary changes by our PBM, as well as timely and accurate configuration of medical drugs. This includes overseeing the configuration and testing of pharmacy contracts and medical drugs in the medical claims system, and the strategic management of pharmacy and medical benefits. The role involves managing formulary and medical drug coding changes to minimize member disruption while driving value and better member outcomes, and participating in the negotiation of direct rebates with pharmaceutical manufacturers. The Director is responsible for the development, monitoring, and reporting of key performance indicators (KPIs) related to formulary and medical drug management, including cost and utilization. They participate in the development of Clinical Programs and strategies to improve member health outcomes, collaborating with Clinical Program Managers. The role involves developing methods to identify, quantify, and measure total cost of care savings opportunities related to formulary and medical drug management techniques, and reporting on these initiatives to senior leadership. Collaboration with stakeholders is key for creating new drug and utilization management strategies, and for communicating and educating members, providers, pharmacies, and internal business partners on formulary, prior authorizations, specialty drugs, and other initiatives. The Director oversees the Pharmacy & Therapeutics and Value Assessment Committees, including preparation of materials and stakeholder education. They ensure the development of clinical policies and criteria for managing specialty and non-specialty medication utilization in accordance with formulary management best practices, and ensure compliance with regulatory guidelines for Medicaid, Medicare, Exchange, and future lines of business. This includes overseeing the development and execution of policies, trainings, and procedures to ensure compliance with new and existing regulations and accreditation standards. The role involves regular data analysis to identify process improvement opportunities and working with the appeals and grievance team to improve formulary management and communication. The Director is accountable for motivating, hiring, training, coaching, professional development, succession planning, performance appraisals, and disciplinary actions of staff. Any other job-related duties as requested will also be performed.

Requirements

• Bachelor's degree in Pharmacy required
• Three (3) years of managed care experience required
• Two (2) years of formulary management experience in Medicare, Marketplace or Medicaid lines of business required
• Experience working with government lines of business (Medicare, Medicare, or Marketplace) in multiple states or markets required
• Experience participating in or leading a P&T Committee required
• Previous managerial experience required
• Unrestricted registered pharmacist (RPh) Licensure in state of practice required
• Intermediate proficiency in Microsoft Outlook and Microsoft Word
• Advanced proficiency in Microsoft PowerPoint and Microsoft Excel (able to create presentation-ready charts & graphs, Pivot tables/charts)
• Strong problem solving skills
• Advanced presentation skills– ability to interact effectively with internal/external audiences, summarize work for different audiences and create basic charts & graphs from work
• Familiarity with medical terminology and medical claims billing
• Extraordinary attention to detail
• Ability to synthesize large amounts of findings orally and in writing
• Excellent time management & leadership skills - effectively, efficiently & accurately managing multiple tasks simultaneously under tight timelines for yourself & your team in a fast-paced healthcare environment
• Proven track record of creative of “out of the box” thinking
• Ability to work independently & within a team environment in a fast-paced healthcare environment
• High level of curiosity and/or desire to be innovative/creative
• Ability to maintain confidentiality and act in the company’s best interest
• Strong oral, written, and interpersonal communication skills
• Excellent leadership, management and supervisory skills and experience
• Energetic, enthusiastic, and politically astute
• Ability to act with diplomacy and sensitivity to cultural diversity
• Responsive to a changing environment
• Strategic management skills
• Conflict resolution skills
• Planning, problem identification and resolution skills
• Strong decision making skills
• Customer service skills with the ability to interact professionally and effectively with members, providers, internal business areas and colleagues
• Strong analytical skills with the ability to create reports and interpret operational, utilization and financial data
• Proven problem-solving skills with the ability to look for root causes and develop implementable, workable solutions

Nice To Haves

• Doctorate of Pharmacy (Pharm.D.) preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Experience with state-mandated formularies or drug lists preferred

Responsibilities

• Ensures the efficient operational management of the formulary and medical drug management and clinical policy/criteria development teams with emphasis on execution, outcomes, continual improvement and performance enhancement
• Oversees the monitoring of and educates stakeholders on the drug development pipeline and strategies we will employ to appropriately manage new and existing drugs
• Ensures business partner accountability for the accurate and timely implementation and testing of benefit and formulary changes by our PBM as well as timely and accurate configuration of medical drugs
• Oversees the configuration and testing of pharmacy contracts and medical drugs in the medical claims system
• Oversees the strategic management of the pharmacy benefit and medical benefits
• Oversees the management of formulary and medical drug coding changes to minimize member disruption but drive value and better member outcomes
• Participates in the negotiation of direct rebates with pharmaceutical manufacturers
• Oversees the development, monitoring and monthly (or more frequent) reporting on key performance indicators (KPIs) related to formulary and medical drug management, including but not limited to cost and member, provider and/or drug utilization
• Participates in the development of Clinical Programs and clinical strategies to drive better member health outcomes
• Ensures team collaboration with Clinical Program Mangers to create and improve programs that drive better member health outcomes
• Develops methods and strategies to identify, quantify and measure total cost of care savings opportunities related to formulary management and medical drug management techniques
• Reports on the progress of total cost of care initiatives to senior leadership
• Collaborates with other stakeholders to create new and creative drug and utilization management strategies
• Collaborates with other teams to communicate and educate members, providers, pharmacies, and internal business partners on formulary, prior authorizations, specialty drugs and other initiatives
• Oversees the Pharmacy & Therapeutics and Value Assessment Committees, preparation of meeting materials & presentations, and education of stakeholders following committee meetings
• Ensures development of clinical policies and criteria to effectively manage specialty and non-specialty medication utilization in accordance with formulary management best practices
• Ensures regulatory and compliance guidelines are met for Medicaid, Medicare, Exchange and future lines of related to formulary and medical drug management and the development of clinical policies and criteria
• Oversees the development and execution of policies, trainings, and procedures to ensure compliance with new and existing regulations and accreditation standards
• Analyzes data regularly to identify process improvement opportunities relating to formulary and medical drug management, as well as clinical policy and criteria development
• Works with appeals and grievance team to understand how to better improve formulary management and/or communication to reduce inappropriate or avoidable appeals and grievances
• Accountable for motivating, hiring, training, coaching, professional development, succession planning, performance appraisals, and disciplinary actions of staff
• Perform any other job related duties as requested.

Benefits

• In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
• We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

What This Job Offers

• Job Type: Full-time
• Career Level: Director