Review clinical/financial recommendations and strategies provided by the PBM’s clinical pharmacists to determine feasibility and appropriateness, and ensure flawless implementation of these initiatives. Monitor the initiatives to measure results.
Monitor pharmacy trends; recommend process, product, and program improvement; plan, implement, and monitor changes.
Review pharmacy utilization reports generated by PBM, in coordination with the PBM clinical team, in a collaborative effort to improve quality and contain costs.
Support medical management goals by being a point person for the implementation of all pharmacy-related clinical programs and initiatives.
Work with PBM to identify and resolve any operational issues.
Provide support and attend all pharmacy-related meetings and committees sponsored by the line of business; participate on the Enterprise P&T Committee.
Generate necessary provider and member communications related to the pharmacy program.
Keep abreast of industry trends and regulatory changes in the pharmacy industry and evaluate their effect on pharmacy contracts and services.
Provide on-site education and training for the line of business’s Providers on formulary and pharmacy procedures.
Develop strategies, along with our PBM partners, to improve HEDIS ratings and other quality measures.
Ensure compliance with NCQA accreditation standards.
Participate in on-site visits to hospital systems, selected physician group practices, and pharmacies.
Act as the main point of contact for physicians and plan staff who are experiencing problems with the pharmacy program (decision, process, timeliness, etc.).
Act as the main point of contact for the State Agency and respond to all pharmacy inquiries in a timely manner.
Support the Fraud and Abuse program system oversight.
Communicate any suspected fraud discovered by the contact center staff. Recommend a course of action for Providers where patterns appear outside of guidelines and generally accepted pharmacy standards.
Work closely with PBM to ensure appropriate provider/member outreach is made at the local level to improve overall program quality. ·
Coordinate with a line of business’s compliance team on key operational and medication management issues identified through plan oversight and monitoring of PBM.
Identify cost containment initiatives specific to line of business; make recommendations and offer program improvements; coordinate initiatives with PBM. ·
Develop/build relationships with the local behavioral health providers, PerformCare staff, and PBM with the goal of improving the delivery of health care programs.
Create and support an environment that fosters teamwork, cooperation, respect, and diversity.
Collaborate and coordinate with PBM to create opportunities and efficiencies, and improve and create value within the Enterprise.
Supervise and develop pharmacy technicians to support the plan’s needs.
Perform other job-related duties, as assigned.
Education/Experience
Pharm.D. required
Registered Pharmacist with a current, active, unrestricted Pharmacist license in Pennsylvania, where the plan operates.
Minimum of three (3) working years of Medicaid pharmacy benefits management experience required. Retail/community pharmacy experience alone does not meet the requirements for this position.
Other Skills
Highly effective communicator able to establish relationships within and across departments.
Highly organized and responsive to a challenging environment that may require urgent turnaround times.
Innovative and Strategic Thinker.
Our Comprehensive Benefits Package
Flexible work solutions include remote options, hybrid work schedules, competitive pay, Paid Time Off (PTO) including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.
Your career starts now. We’re looking for the next generation of health care leaders.
At AmeriHealth Caritas, we’re passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com
For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.
