Manager, Pharmacy Quality

Job ID: J121272
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 25, 2018

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Description

JOB SUMMARY

This job manages a number of clinical and financial aspects of the prescription drug benefit for all lines of business. These aspects include continuous formulary development, pharmacy and therapeutics process, inception and implementation of clinical policy and programs such as prior authorization, step therapy and quantity limit programs, utilization review, quality management, compliance with regulatory standards, reports, etc. in a manner that will improve the quality of care while controlling utilization and containing costs.

ESSENTIAL RESPONSIBILITIES

  • Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
  • Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
  • Lead the development of policies and procedures related to drug utilization review programs.
  • Evaluate total cost of care, as well as, direct pharmacy costs.
  • Manage all drug utilization review programs in all settings.
  • Develop, maintain, and measure effectiveness of various drug utilization programs.
  • Ensure that all quality guidelines, as well as, legal regulations are met.
  • Direct clinical utilization review programs for all drug-related claims.
  • Consult, develop, and implement on policy and procedure for drug utilization to ensure optimal quality of care and cost effectiveness.
  • Provide clinical expertise for formulary management programs, present information about new drugs; implement prior authorization programs, step therapy programs, quality limits and the like.
  • Perform drug class evaluations, monograph development and clinical decision support.
  • Serve as a resource of drug information for other departments.
  • Maintain the Highmark on-line drug formularies.
  • Publish changes, additions, deletions, new programs in all applicable publications and /or on-line resources.
  • Other duties as assigned or requested.

EDUCATION

Minimum

  • Bachelor's Degree- Pharmacy

PREFERRED EDUCATION

  • Pharmacy (Pharm-D)

EXPERIENCE

Minimum

  • 3 years of experience as a registered pharmacist
  • 1 year of managed care experience

Preferred

  • Pharmacy Residency (PGY1) and/or Board Certification (e.g., BCPS, etc.)
  • 3 years in a management/leadership role with a managed care insurer or pharmacy benefits management company
  • Utilization Management process experience
  • Data analysis of drug and/or medical claims
  • Experience in reviewing and making recommendations based on comparative effectiveness data and/or drug trend reports

SKILLS

  • Knowledge of managed care and utilization management processes
  • Knowledge of Formulary Management, Clinical Policy, Care Cost Management, and Quality Improvement initiatives and programs
  • Knowledge of regulatory requirements and measurements such as Medicare, Medicaid, DOL, DOH, DOI, NCQA, STARs, QRS, affecting business
  • Ability to speak publicly and communicate effectively through a variety of mediums (electronic, written, etc.)
  • Using logic and reasoning to identify the pros and cons of alternative solutions, conclusion, or appropriate approaches to challenges
  • Understanding the implications of new information for both current and future decision making (i.e., seeing the big picture)

LICENSES AND CERTIFICATIONS

REQUIRED

  • Active and Unrestricted Pharmacist (RPh) License
  • Pennsylvania Licensed or eligible

TRAVEL REQUIREMENT

0 - 25%
 

LANGUAGE REQUIREMENT (other than English)?  
None

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
 

Position Type

Office-Based

Office-Based Positions

An employee in this position works in an office environment.  The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email).  The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks.  The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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