Dean Health Plan, Quality & Care Management - Director-Pharmacy Services | Madison, WI | SSM Health

Dean Health Plan, Quality & Care Management - Director-Pharmacy Services

Are you looking for a great opportunity - Director Pharmacy Services Health Plan?

DHP is an exciting organization, growing both geographically and through product and service line extensions; our focus is on designing programs and services specific to the local communities and populations we serve.  We offer a flexible work environment and encourage employee participation in compassionate activities that benefit our local communities. 

A successful candidate:

  • Serve as the single point of accountability for pharmacy cost and utilization within the health plan; leveraging deep experience within the managed care space
  • Dynamic and strategic visionary able to engage with our Integrated Delivery Network (IDN), network providers and health plan colleagues to improve the health of our membership in a responsible, cost efficient manner
  • Supportive and engaging manager with a proven record of staff development and progression planning
  • Poised presenter comfortable serving in an outward-facing position that represents the health plan within our providers, members, employer groups, vendors and across the health plan industry

  • Passionate about population health, keeping the member top of mind in all facets of work

Directs the pharmacy clinical and operational strategy for organization. Provides oversight for clinical initiatives, operations, quality of the pharmacy benefit, vendor management, and accreditation and regulatory compliance. Directs pharmacy management initiatives, monitors and analyzes drug utilization and quality patterns across products. Oversees relationship with pharmacy benefit manager (PBM) to ensure optimum and market-competitive PBM services, formulary management, rebate generation and clinical program creation/ administration. Works closely and cross-functionally to maximize operational and financial performance.

PRIMARY RESPONSIBILITIES

  • Manages the overall relationship and oversight of PBM as it relates to all delegated activities. Establishes and maintains strict controls and accountability for all PBM and specialty pharmacy delegation oversight. Partners with the compliance department to ensure completion of all required tasks.
  • Works in collaboration with PBM, internal and external partners to establish a drug formulary that supports compliant, cost-effective requirements of organization, development of practice guidelines and recommendations for drug utilization review (DUR) programs.
  • Responsible for the development and maintenance of pharmacy policies and procedures to be compliant with OCI and CMS regulations as well as NCQA accreditation requirements. Ensures the quality and accuracy of pharmacy departmental policies and end-to-end work processes. Responsible for creating and operationalizing the process related to pharmacy related medical policies and prior authorization requirements. Accountable for pharmacy HEDIS and Part D STAR measure improvement programs.
  • Responsible for participation and remediation steps identified in the annual pharmacy clinical internal audit. Assists in reporting on the impact of the pharmacy spend on profit and loss statement with a focus on financial, clinical and operational metrics relative to historical and targeted results.
  • Leads or supports the identification, development and implementation of pharmacy based care management initiatives; compiles and analyzes medical and pharmacy data; identifies related member populations; recommends and develops appropriate provider and member interventions; monitors and takes action on results.
  • Identifies opportunities to develop and implement programs for improving care and or controlling drug or overall healthcare costs. Responsible for value initiatives and cost management related to pharmacy, both within the Integrated Delivery Network (IDN) and across the contracted network, working closely with leaders, providers and other external stakeholders. Serves as the clinical pharmacy expert on a variety of committees and workgroups. Represents the health plan in external relationships with members, providers, employer groups, vendors, regulatory agencies and other health plans.
  • Supervises quantitative and qualitative analyses/ evaluation; collaborates to identify opportunities for improving cost effectiveness and quality of care and services, and to monitor and evaluate performance and to evaluate outcomes of programs related to pharmacy programs and interventions.
  • Assists in the review of prior authorization requests and summarizes the approval and denial of such requests when necessary and conducts research into drug therapy related questions.
  • Anticipates technology solutions; manages vendor performance and relationships.
  • Manages, hires, develops, and retains a high performing pharmacy team of clinical and operations staff.
  • Develops and manages department budget.
  • Performs other duties as assigned.


EDUCATION

  • Bachelor's degree in Pharmacy or PharmD degree from an accredited school of pharmacy


EXPERIENCE

  • Seven years' experience in pharmacy operations or administration in a managed care setting, with five years' leadership