Director, Clinical Pharmacy Services - Priority Health

About the Role

Priority Health, the second largest and fastest growing health plan in Michigan, is seeking a Director, Clinical Pharmacy Services to administer and provide oversight for all aspects of Pharmacy Operations. This role oversees all product lines including Commercial, Self Funded, HCR, Medicaid, MIChild, and Medicare, and is responsible for the successful integration of Pharmacy Benefit Administration. The Director will develop policies, processes, and business practices that support efficient and compliant Pharmacy Benefit Administration and claim adjudication.

Direction Exercised

This position has direct operational oversight of the Pharmacy Benefit Manager.

Essential Functions

• Engage in complex analytical and conceptual thinking to identify opportunities for operational efficiencies leading to increased customer experience and streamlined adjudication and prior authorization processes.
• Oversee and collaborate with direct reports to implement and carry out department strategies and objectives.
• Develop detailed plans and schedules, identifying goals, objectives, risks and resource allocation.
• Investigate future functionality and enhancement requests with pharmacy vendors.
• Accountable for oversight of PBM performance expectations for benefit set-up, compliant claim adjudication, accurate formulary set-up, timely and accurate benefit set-up.
• Monitor performance for significant deviations in quality, cost or schedule.
• Collaborate with PBM to increase performance and establish return to service plans when PBM is under performing.
• Develop department policies, procedures and standards of care that best align the department and Priority Health for current and future challenges, and manage implementation of the same.
• Ensure close alignment with Director of Clinical Programs to ensure clinical decisions and policies are accurately documented and operationalized.
• Ensure policies and procedures support compliance with NCQA, CMS, Medicaid, HIPAA and PPACA.
• Effectively meet/exceed NCQA, CMS, HIPAA, departmental and other governmental requirements.
• Oversee compliant operations for Medicare Part D Pharmacy Benefit including adherence to CMS regulations through detailed monitoring plans for Priority Health as well as first tier, downstream and related entities (FDR's).
• Oversee compliant operations and monitoring of pharmacy utilization management.
• Ensure staffing levels are sufficient to maintain service levels.
• Develop, implement and maintain performance tracking and trending tools to allow for daily monitoring of the team's performance level for all functions to ensure that departmental, CMS, Medicaid, NCQA and PPACA standards are met.
• Effectively develop, prioritize and implement project plans as assigned by management.
• Develop and monitor operating budget for Pharmacy Operations and Pharmacy Utilization Management, and manage the budget to meet or reduce operating margin goals.
• Manage contracts with Pharmacy Vendors (PBM, Specialty Pharmacy, Previous PBM, Prior-Authorization Software vendor and any other vendors as assigned by AVP Pharmacy Programs).
• Ensure contract is operationalized and adhered to as written by vendors.
• Oversee Performance Guarantees, collaborating with vendors to meet or exceed performance goals.
• Create corrective action plans as needed for return to service levels.

Qualifications

• Doctorate of Pharmacy Degree.
• 3 years of relevant experience in Pharmacy Benefit Administration.
• 3 years of relevant experience in a leadership role.
• 3 years of relevant experience working in an organization of size and pharmacy benefit complexity comparable to Priority Health.
• 3 years of relevant experience managing Pharmacy program operations and vendor programs.
• LIC-Clinical Pharmacist - State Other than Michigan Upon Hire required OR LIC-Clinical Pharmacist - State of Michigan Upon Hire required.

Benefits

• Comprehensive benefits package to meet your financial, health, and work/life balance goals.
• On-demand pay program powered by Payactiv.
• Discounts directory with deals on restaurants, phone plans, spas, and more.
• Optional identity theft protection, home and auto insurance.
• Traditional and Roth retirement options with service contribution and match savings.

Schedule

• Full time, Day shift.
• Weekly Scheduled Hours: 40.
• Hours of Work: 8 a.m. to 5 p.m.
• Days Worked: Monday to Friday.

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