Pharmacist-PBM

About the Role

This position is responsible for the development, maintenance, and evaluation of pharmacy clinical initiatives and utilization management programs to assure cost-effective and quality pharmaceutical services and benefits for plan members. The incumbent manages the drug formulary program, clinical activities, and oversees clinical program administration by the pharmacy benefit management (PBM) company. The role serves as a clinical resource for committees and workgroups such as Pharmacy and Therapeutics Committee, Medical Policy Committee, Quality Management Committee, Delegation Oversight, and HEDIS/NCQA.

The incumbent possesses strong clinical and analytical skills, sound decision-making capabilities, and excellent communication skills to interact with medical professionals, managed care clients, and external organizations.

Responsibilities

• Formulary management including drug evaluation, P&T Committee, and related physician and member collaterals
• Pharmaceutical utilization and trend management via pharmacy clinical initiatives
• PBM vendor clinical services and programs oversight
• Specialty pharmaceutical management
• Pharmacy clinical and utilization management criteria, protocol, policies, and procedure development
• Provide clinical and drug information support
• Maintain regulatory compliance, including Medicare Part D, and accreditation standards
• Develop member and provider educational programs
• Conduct presentations and training
• Maintain provider and pharmaceutical industry/drug manufacturer relations
• Staff supervision

Requirements

• Pharmacy degree and current Pennsylvania pharmacy license required
• Advanced pharmacy degree (Masters or Pharm.D.) preferred
• Experience in developing pharmacy clinical protocols, policies, and procedures
• Experience in design and deployment of programs to increase quality of care and decrease costs
• In-depth knowledge of drug formulary systems and drug evaluation processes
• Broad knowledge of outpatient drug benefits and utilization management programs
• Knowledge of pharmacy claims processing and applicable state/federal laws
• Knowledge and experience with Medicare Part D and NCQA accreditation preferred
• Working knowledge of medical and pharmacy data integration to close gaps in care and facilitate care coordination
• Managed care knowledge and experience preferred

Skills

• Strong interpersonal and team skills with the ability to work and interact externally and internally
• Ability to communicate effectively with varied audiences, lead meetings, develop teamwork, and deliver verbal presentations
• Ability to take direction from various levels of staff and perform project work with minimal supervision
• Strong clinical and analytical skills with sound decision-making capabilities
• Ability to assess utilization data to identify new opportunities

Schedule

This position is classified as hybrid, requiring onsite work on Tuesdays and Wednesdays.

Benefits

• Comprehensive medical, dental, and vision coverage
• Retirement plan
• Generous paid time off, including holidays and volunteer time off
• Incentive plan
• Tuition reimbursement

Pay

Base pay is influenced by qualifications, relevant experience, and anticipated contributions, along with internal pay equity and external market-driven rates. The salary range has not been adjusted for geographical location.

Work Environment

• Typical office conditions
• Sedentary work involving significant periods of sitting, talking, hearing, keying, and performing repetitive motions
• Visual acuity required for close inspection of written and computer-generated documents
• Occasional lifting and/or moving up to 5 pounds
• Ability to work over 40 hours per week
• Travel less than 1%, including occasional overnight travel and travel between Capital Blue Cross locations