Clinical Pharmacist

The Role

The Medicare (PDP) Clinical Pharmacist will provide clinical oversight of the benefits, formulary, and clinical programs to support the NEJE product offerings.The candidate will engage with the PBM, Sales, Marketing, Product Management, Actuarial and other business areas to promote and retain Medicare employer-groups, focusing on strategically aligning clinical pharmacy recommendations with employer-group strategies.This role will also be responsible for clinical oversight of the delegated PDP functions.

RESPONSIBILITIES

• Participation in regular workgroups to ensure continuous process improvement and compliance.
• Actively participate in the development, execution and ongoing maintenance of clinically appropriate and cost effective programs to help control the escalating costs of pharmaceuticals and utilization rates.
• Collaborate with other NEJE partners to evaluate programs after implementation to ensure objectives are met.
• Oversee the formulary and clinical programs for Blue Medicare Rx to ensure compliance with all CMS requirements for administration and reporting.
• Monitor transition program compliance and ongoing coding maintenance and claims oversight to ensure accuracy. Perform clinical intervention and data analysis to identify the cause, resolve the issue and avoid further member impact.
• Oversee Utilization Management programs implemented and managed by PBM to ensure clinically appropriate utilization and promotion of the most cost effective therapies.
• Active collaboration with internal partners including but not limited to Pharmacy Operations, Member Service, Compliance, Product Management, Medical Directors, Legal, Sales/Marketing/Product and external vendors/customers (e.g. PBM, P&T Committee) to develop, communicate and implement PDP formulary and clinical program offering.
• Oversee Medication Therapy Management (MTM) programs to meet the CMS requirements. Perform monthly analysis of MTM data to identify members who qualify for a CMR who have not participated.
• Provide clinical support and oversight of CMS required clinical programs to remain compliant and operationally effective. Review patient safety, appropriate utilization, and access to care reporting.
• Continuous oversight, QA testing, and close monitoring of rejected pharmacy claims to ensure formulary coding accuracy and access to care in a timely manner
• Partner with Medicare Pharmacy Operations Clinical Manager to provide oversight to PBM delegated coverage determination activities.
• Special projects as assigned.

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Minimum of professional Registered Pharmacist degree required. Graduate study in a business, public health, or health policy field will be favorably considered.
• Unrestricted current and valid license to practice pharmacy in the state of Massachusetts and/or in any other relevant/applicable state
• 2-5 years prior pharmacy management experience preferred
• Experience in direct supervision of technical support staff for clinical and/or service and operational programs is desirable.
• Experience in a managed care setting, either from the provider, the payer, or the PBM side of the industry, is required.
• Proficiency in standard computational office-suite applications, including word-processing and relational database manipulation is required.

SKILL AND BEHAVIORAL COMPETENCIES REQUIRED:

• Excellent written and oral communication skills
• Excellent interpersonal skills
• Strong organizational and time management skills, including ability to work independently and prioritize multiple projects and assignments
• Demonstrated strength in analysis, identification of problems and issue resolution
• Excellent skills in teamwork and team approaches to goal setting and attainment
• Demonstrated ability to establish and maintain positive, effective working relationships with staff, internal and external customers
• Must be results oriented.

High school degree or equivalent required unless otherwise noted above

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto stay "in the know" on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.