Job DescriptionThis position will have responsibility for all clinical aspects related to administration and operations of the strategic business unit(s) program surrounding Medicare Part D. The successful incumbent will develop and manage internal and external relationships with key thought leaders in the industry to maintain compliance with Centers for Medicare and Medicaid Services (CMS) guidance and ongoing prospective and retrospective analysis of clinical attributes related to formulary and plan design, member health outcomes, and pharmacy delivery models. Will have problem solving and critical thinking skills encompassing the multifaceted delivery of the Medicare Part D benefit from multiple aspects such as Prescription Drug Plan (PDP), Medicare Advantage Plan, Employer Group Waiver Plan (EGWP), and/or Special Need Plans. Will work in a team environment to garner and manage the internal resources and communicate through all the strategy of the organization. This position will ensure qualified clinicians are accountable for decisions affecting consumers and provides guidance for clinical operational aspects of the program.
- Reviews and interprets all existing and new Health Plan Management System (HPMS) guidance from CMS re: clinical elements of the Part D program (e.g., transition, protected class drugs, formulary changes, ESRD, Hospice, etc.)
- Administers formulary and oversight of adherence and retrospective Drug Utilization Review (DUR).
- Develops, monitors, improves operational controls related to clinical aspects of the Part D program, particularly Formulary Administration and Coverage Determinations, Appeals and Grievances.
- Develops claims monitoring (paid and rejected) criteria related to clinical aspects of the Part D benefit; reviews claims daily to flag suspect items for detailed review with SMEs.
- Works with the compliance team and medical director to develop, maintain and provide clinical leadership in the development of new methodology and technology that allows SBU to stay on the cutting edge of high quality, pharmacy benefits management.
- Operationalizes and monitors clinical efforts pertaining to reporting (maintenance and ad hoc), adjudication, Coverage Determinations and Appeals.
- Drives the formulary definition, with associated rebate contracting considerations, for the annual Part D bid.
- Participates in internal and external audits.
- Ensures all programs are of the highest clinical quality and integrity and provides clinical oversight to all clinical areas within the department.
- Problem solves and applies critical thinking driving multidisciplinary efforts and planning.
- Oversees downstream providers to ensure delivery of services according to contractual agreements held between Magellan and vendor.
- Participates in the development of strategic and operational goals and plans for the growth and ongoing clinical operations of SBU.
- Supports sales of pharmacy services.
- Produces product/service pipeline monitoring and reporting.
General Job Information
TitleSr. Director, Clinical Pharmacy Operations, Medicare Part D
Job FamilyPharmacy Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date10/9/2019
Date Requisition Created10/9/2019
EducationBachelors (Required), PharmD: Pharmacy (Required)
License and Certifications - RequiredPharmD - Doctor Of Pharmacy, State Licensure - Pharmacy
License and Certifications - Preferred
Other Job Requirements
- Minimum 10+ years of Pharmacy Benefit Management (PBM), Pharmacy or Health Plan experience.
- 5+ years of Medicare Part D (MedD) experience.
- Ability to read, interpret, and operationalize Medicare Part D guidance and ability to understand how various aspects of the guidance is interdependent and related.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
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