- Pharmacy Clinical Leadership and Strategy
- Works with the Chief Medical Officer to establish a compelling clinical vision for pharmacy
- Serves as the clinical leader for pharmacy, and as such, provides leadership in managing internal and external relationships with partners, and in identifying new and innovative strategic and customer-focused opportunities, advising the Chief Medical Officer and other executives
- Serves as the primary contact for all pharmacy / formulary-related initiatives, financial/rebate performance, trend evaluation, and corresponding clinical strategy & business plan development
- Maintains a thorough knowledge of industry trends, as well as trends related to new drugs and therapies, and incorporates this knowledge into formulary management strategies
- Collaborates with delegated vendors to fully leverage data analytics for identification of utilization issues around formulary design and new program development
- Develops and maintains a high quality, cost-effective formulary; participates in the bid development and submission process, as it relates to formulary and benefit design
- Ensures pharmacy initiatives are customer-focused, and aligned with Mutual of Omahas culture, strategy, and brand promise
- Clinical Quality and Outcomes
- At the direction of the Chief Medical Officer, leads or participates in clinical teams and committees (e.g., Pharmacy Management Committee, Quality Management Committee) necessary to ensure plan performance as related to quality, safety, access, and adherence, while effectively managing costs
- Works closely with strategic partners to ensure alignment on clinical goals and outcomes, as well as for monitoring ongoing performance on STARS measures
- Ensures that benefits and clinical programs are designed in a way to strategically support performance on STARS measures
- Monitors delegated DUR and MTM program performance
- Communicates and leads effectively to ensure physicians and other key stakeholders understand pharmacy trends and opportunities
- Compliance and Delegation Oversight
- Is responsible for oversight of delegated Part D operations for Mutual of Omahas Medicare Advantage and Prescription Drug Plans, ensuring compliance with CMS Medicare Advantage regulations, and working collaboratively with the Chief Compliance Officer
- In this capacity:
- Designs, launches and establishes appropriate governance for the monitoring program for Medicare Advantage and Prescription Drug Plan operational areas including Part D / PBM / Coverage Determinations, Appeals and Grievances (CDAG)
- Reviews key Part D functions for evidence of meeting compliance requirements for accuracy in key areas including, but not limited to, claims, coverage determination, formulary administration, PDE, and reporting
- Establishes a process for analysis & oversight of vendors rejected claims, including those areas involving high-risk medications, quantity limits, transition fills, and Part B vs. Part D coverage determinations
- Ensures delegated vendors are meeting contractual obligations and service-level agreements
- Oversees delegated vendors and provides guidance through auditing, monitoring, and ad hoc oversight processes as necessary
- Pharmacy Financial Performance
- Reviews trends in Part D claims data and other analytics / reporting to understand plan financial performance and opportunity identification
- Uses a data-driven approach to assist in benefit design as part of the bid process
- Plays a critical leadership role in contracting with delegated vendors
- PharmD and licensed as a pharmacist.
- 5+ management / leadership experience.
- 5+ years managed care experience and experience working for or providing oversight of a PBM.
- 4+ years of Medicare Part D, including Medicare Advantage Plan or Prescription Drug Plan, experience.
- A minimum of 3 years' experience in Clinical Decision-Making, Coverage Determination and Reconsideration processing.
- Expert knowledge of Medicare Part D regulations.
- Expertise in managed care Part D pharmacy operations and oversight programs.
- Leadership in clinical quality & safety, benefit design, clinical program design, and oversight
- Excellent interpersonal, verbal and written communication and presentation skills.
- Highly organized, influential and the ability to build consensus within all levels of organization.
- Ability to analyze, interpret and utilize significant data to make sound business decisions
- Excellent leadership skills and team building skills; ability to empower team members to meet individual, team and company objectives and motivate.
- Ability to travel up to 20%
- Ability to teach and foster development in others