Clinical Pharmacy Manager
The Clinical Pharmacy Manager of Government Programs directs and manages the clinical and operational aspects of providing pharmacy prior authorization (coverage determination) and appeals services for all Steward Health Choice health plans which include both Medicare Part D and state Medicaid plans. Responsibilities include: developing and maintaining policies and processes for the clinical pharmacy department that are compliant with all relevant laws, regulations, accreditation requirements and contracts; working collaboratively with the Pharmacy Benefit Management (PBM) on developing, implementing, and managing the application of coverage criteria to ensure clinically appropriate coverage determinations for members within the prior authorization (PA) system; assessing PA system attributes to ensure appropriate functionality exists to conduct coverage determinations consistent with clinical practice and regulatory requirements; measuring performance of staff to maintain fiscally responsible and compliant medication coverage determination outcomes; developing and managing the clinical pharmacy team who conducts medication prior authorizations (coverage determinations) and appeals which includes assessing staff performance and auditing work product to ensure clinical quality and productivity standards and performance metrics are met; and, providing delegated oversight activities that ensure appropriate performance of vendor based coverage determination operations if applicable.
The Clinical Pharmacy Manager of Government Programs works closely with National Director of Pharmacy, health plan pharmacy staff, medical staff and Steward Healthcare leadership teams to develop, implement and refine strategies for innovative and cost-effective medication coverage based on performance metrics defined by regulator contracts, accreditation standards, and organization goals.
Manage clinical pharmacy operations (specifically people, process and technology) efficiently and effectively and serve as key point person for medication coverage determination system functionality, and staff operations and outcomes:
- Implement, maintain and enforce policies and procedures for medication coverage determinations (drug authorizations and service requests) in accordance with accreditation, state and federal guidelines and contract requirements including but not limited to request turn-around times, clinical decision integrity and quality, and appropriate member and provider notifications.
- Implement and maintain drug use criteria and protocols within pharmacy PA (coverage determination) system.
- Work closely with designated PBM to ensure clinical coverage criteria and system function consistent with government regulations and contract requirements.
- Work collaboratively with medical and pharmacy policy staff and PBM clinical pharmacists and account team to educate Steward Health Choice clinical pharmacists and manage performance of clinical criteria used for coverage determinations.
- Provide guidance to the pharmacist and technician staff regarding coverage determination (or prior authorization) activities, member and provider outreaches, and other Medicaid and Medicare medication coverage requirements including but not limited to meeting turn-around times for requests.
- Assess and manage performance of pharmacist and technician staffs within pharmacy coverage determination systems.
- Manage high performance clinical pharmacy team who conducts medication coverage determination operations which includes assessing staff performance and auditing cases to ensure clinical quality and productivity standards and performance metrics met.
- Assess PA system attributes and capabilities to determine if appropriate functionality exists to conduct coverage determinations consistent with clinical practice and regulatory requirements; if needed develop plan for new system and functionality.
- If appropriate provide delegated oversight and audit activities that ensure appropriate performance of vendor-based coverage determination operations.
- Collaborate and communicate with interdepartmental staff and providers.
- Work closely with designated PBM to ensure clinical coverage criteria, system, reports and claims adjudication logic are compliant with government regulations and requirements.
Educate and train pharmacy and policy teams, clinical operations staff including medical PA team, case managers and Medical Directors, and Steward Health Choice department leadership on medication coverage determination systems, staff operations and department performance requirements and metrics.
- Work with health plan pharmacists, clinical policy staff and Medical Directors to ensure P&T Committee decisions on medication clinical coverage criteria are implemented and clinical pharmacy staff are educated on appropriate use.
- Conduct educational sessions on drug coverage criteria, pharmacy PA system functionality, and staff performance. Sessions may be individual or group sessions and are provided in various formats. Session meeting minutes should be maintained for all education sessions.
- Work closely with Clinical Operations leadership to develop and analyze performance reports to optimize system and staff performance as well as project future business needs.
- Complete other responsibilities and duties that may be assigned by management.
Instill a culture of compliance in the pharmacy department through motivation, communication and assessment of staff. Provide expertise and leadership through regulatory audits of the Steward Health Choice plans. Ensure accuracy of pre and post audit deliverables. Performs other position appropriate duties as required in a competent, professional, and courteous manner.
- Pharmacy degree from an accredited college of pharmacy, Pharm D preferred.
Certification and License:
- Arizona pharmacist license required.
- Pharmacy licensure in good standing.
Years of Experience:
- At least five (5) years of experience with a health plan pharmacy department or Pharmacy Benefit Manager (PBM).
- Two (2) years of experience managing pharmacy teams or staff.
- At least two (2) years of practice experience in applying clinical drug use criteria.
- At least (2) years of Medicare Part D coverage determination and appeals experience.
- Proficient in the principles and practices of managed care pharmacy.
- Broad based knowledge in a variety of pharmacy disciplines.
- Knowledge of Medicare and Medicaid regulations and guidelines regarding formulary administration, coverage determination and appeals.