Mgr. Clinical Pharmacy Program

About the role

The Clinical Pharmacy Program Manager provides highly specialized integrated clinical pharmacy services to the health plan. This position is responsible for managing both clinical and operational functions for pharmacy benefit administration for the assigned line of business. The Clinical Pharmacy Program Manager will be responsible for supervising clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned.

Community Health Choice, Inc. (Community) is a non‑profit Managed Care Organization (MCO) licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 members in Medicaid STAR, CHIP, Health Insurance Marketplace plans, and a Medicare Advantage Dual Special Needs plan (HMO D‑SN). The organization is URAC‑accredited, offers care management programs for asthma, diabetes, and high‑risk pregnancy, and is an affiliate of the Harris Health System while remaining financially self‑sufficient.

Responsibilities

• Review medical and pharmacy benefit claims data for trends and outliers to identify opportunities to enhance medication UM strategies on high‑cost drugs, formulary strategies, and Fraud, Waste, Abuse (FWA) reporting; lead Complex Medication Management program initiatives.
• Perform utilization management review of drug requests as assigned, including but not limited to prior authorization review, appeals, non‑formulary exception and override requests.
• Analyze utilization and prior authorization data to identify drug utilization trends and cost‑savings opportunities.
• Conduct oversight over prior authorization criteria and delegated utilization management functions performed by the PBM.
• Serve as a clinical resource supporting Care Management, Service Coordination, and Utilization Management functions on medication‑related projects and inquiries.
• Manage the Medication Therapy Management (MTM) program.
• Supervise clinical pharmacist(s), pharmacy technician(s) and pharmacy student(s) as assigned.
• Actively contribute to achievement of departmental goals, including specific departmental process improvement plans, and perform other duties as assigned.

Requirements

• Bachelor’s degree in pharmacy if candidate does not have a Doctor of Pharmacy degree (Bachelor’s degree not required if candidate holds a Doctor of Pharmacy degree).
• Active pharmacist license in Texas required; or will obtain Texas pharmacist license prior to start date.
• Minimum 5 years of applicable managed care pharmacy experience as a registered pharmacist; or at least 4 years of relevant pharmacy experience plus completion of advanced training (PGY1 managed care pharmacy residency, master’s, or doctorate in a quantitative discipline such as finance, accounting, business administration, or informatics).
• Strong experience with Drug Utilization Management required.
• Minimum 4 years experience in Medicare, Medicaid, and/or Marketplace with a Health Plan or PBM required.
• Experience with Advanced Excel required.

Qualifications

• Doctor of Pharmacy degree preferred.
• Experience with SQL preferred.
• Strong experience with medication management programs preferred.
• Visio preferred.

Skills

• Microsoft Office (Word, Excel, Outlook, Power Point).
• Problem analysis.
• Results oriented.
• Attention to detail.
• Leadership.
• Exceptional verbal and written communication.
• Managing conflicts.
• Customer oriented.
• Ability to work independently with minimal supervision.
• Taking initiative.
• Interpersonal skills.
• Ability to explain and communicate complex ideas with a diverse population.