Vice President - Health Plan Pharmacy

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Lumeris

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Value-Based Care • Physician Engagement • Care Delivery • Accountable Care Models • Healthcare

1001 - 5000 employees

⚕️ Healthcare Insurance

☁️ SaaS

Description

• Responsible for the development, operations, and results of the Essence Health Plan Pharmacy Program, including guiding clients' Pharmacy Benefits Managers (PBMs), negotiating contracts, ensuring compliance with relevant program requirements, and relevant committees, while impacting clinical support across the organization. • Establishes long-range goals, KPIs, and plans. • Monitors financial and operational performance and coordinates activities of senior leaders and their respective functions. • Serves as a member of the senior leadership team responsible for planning, allocating and monitoring resources, identifying and supporting the organization's mission, strategic plan, and quality improvement initiatives. • Provides strategic direction for the department(s). • Oversees, coaches, mentors, motivates, supports, and develops a large cross-functional team of seasoned people leaders. • Oversees or supports goal setting/review, regular guidance and 1-1 check ins, career development/planning, upskilling, resource allocation, staffing, budget management, DE&I initiatives, and other People & Culture programs/activities as needed. • Fosters accountability and collaboration to ensure team member and overall team success. • Identifies, develops, and oversees team member educational needs, with the goal of optimizing skills and knowledge of emerging approaches to quality/process improvement. • Writes, reviews, and seeks approval for policies and procedures, ensuring that both the departmental and organizational needs are met. • Develops, implements, and impacts clinical pharmacy strategies which results in high-quality, cost-effective pharmacy management and outcomes. • Advises on client CMS Account Management calls as requested. • Serves as a subject matter expert for clients' Part D and Part B drug benefit designs as part of the annual CMS bid process. • Oversees daily operations for Part B drug prior authorization and Part D appeals request procedures using best practices and quality standards as defined by CMS and NCQA. • Ensures compliance with all CMS and NCQA pharmacy related regulations and reporting requirements. • Develops and delivers the pharmacy program budget based on the organization's goals. • Monitors, evaluates, and presents Plan pharmacy data including reporting of trends for drug utilization, drug costs, and quality metrics (e.g., Part D Star, NCQA). • Develops and recommends possible strategies to Lumeris clients to promote cost-effective therapy and quality of care for members. • Acts as content creator and Chair of both the Essence Healthcare and Lumeris Pharmacy Oversight Committees. • Serves as an advisor, content creator, and contributing participant in clients' Pharmacy Oversight Committees. • Negotiates PBM and vendor contracts to maintain market competitiveness and support clients' various benefit design requests. • Collaborates with Contracting to support provider contract negotiations, on-site audits, and ongoing monitoring of provider in-office dispensing practices. • Ensures the pharmacy program is prepared for audit and review, and survey and accreditation processes by external monitoring agencies, and clients with delegated pharmacy processes. • Provides subject matter expertise to meaningfully participate in these audits and surveys. • Advises on the preparation of pharmacy data for use in client and provider-specific reports. • Oversees all aspects of the PBM contract for multiple clients, including coordination with client PBMs for formulary management. • collaborates cross-functionally to gain results. • Oversees provider support programs and conducts site visits as necessary.

Requirements

• Registered Pharmacist with a Missouri State license • 15+ years of relevant experience or the knowledge, skills, and abilities to succeed in the role • 7+ years in management/senior leadership or the knowledge, skills, and abilities to succeed in the role • Proven experience in a managed care setting • Expert knowledge of state and federal insurance programs • Extensive knowledge of pharmacy workflow from prescription to claims submission and authorization request processing, compliance/NCQA standards, and audit processes • Expert knowledge of budget creation/management, resource allocation, and contract/vendor management • Superb leadership skills with the proven ability to coach, develop, and motivate a large team • Excellent communication, presentation, and interpersonal skills with the ability to influence at all levels internally and externally • Outstanding project management, analytical, problem-solving, and critical thinking skills with the proven ability to identify, develop, communicate, implement, and impact process improvements and strategic initiatives • Exceptional judgment, business acumen, and collaboration skills • Distinguished ability to create results in a high-performing and high-growth environment • Preferred: Doctor of Pharmacy • Experience with Medicare Part D

Benefits

• medical • vision • dental • well-being programs • 401(k) with company matching • life insurance • paid time off including paid leave • so much more