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

Job Summary:

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.

Essential Functions:

• 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.

Education and Experience:

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

Competencies, Knowledge and Skills:

• 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