About Priority Health
We are the second largest and fastest growing health plan in Michigan focused on improving the health and lives across the state, and we couldn't do it without the incredible talent of our employees. It is their commitment that continues to drive our success as a nationally recognized nonprofit health benefits company. As part of theCorewell Health system, our team members have a unique ability to grow and advance their career while maintaining their seniority and benefits.
The Director, Clinical Pharmacy Services administers and provides oversight for all aspects of Pharmacy Operations. Oversight includes all product lines of business; Commercial, Self Funded, HCR, Medicaid, MIChild and Medicare. This role will have oversight and successful integration of Pharmacy Benefit Administration. Benefit Administration includes, Pharmacy Benefit Manager, Medication Therapy Management, End to End Utilization Management Process, Part D CMS Compliance and Monitoring, Medicaid Compliance, NCQA Compliance, Health Care Reform Compliance, Prior Authorization Software, end to end benefit remediation and service recovery. The Director, Clinical Pharmacy Servicesdevelop policies, processes and business practices that support efficient and compliant Pharmacy Benefit Administration and claim adjudication.
DIRECTION EXERCISED
This position has direct oversight of the following: Operational oversight of the Pharmacy Benefit Manager.
Essential Functions
Engage in complex analytical and conceptual thinking to identify opportunities for operational efficiencies leading to increased customer experience and streamlined adjudication and prior authorization processes. Oversee and collaborate with direct reports to implement and carry out department strategies and objectives. Develop detailed plans and schedules, identifying goals, objectives, risks and resource allocation. Investigate future functionality and enhancement requests with pharmacy vendors.
Accountable for oversight of PBM performance expectations for benefit set-up, compliant claim adjudication, accurate formulary set-up, timely and accurate benefit set-up. Monitor performance for significant deviations in quality, cost or schedule. Collaborate with PBM to increase performance and establish return to service plans when PBM is under performing.
Develop department polices, procedures and standards of care that best align the department and Priority Health for current and future challenges, manage implementation of the same. Ensure close alignment with Director of Clinical Programs to ensure clinical decisions and policies are accurately documented and operationalized. Policies and procedures should support compliance with NCQA, CMS, Medicaid, HIPAA and PPACA. Effectively meet/exceed NCQA, CMS, HIPAA, departmental and other governmental requirements.
Compliant Operations for Medicare Part D Pharmacy Benefit including adherence to CMS regulations through detailed monitoring plans for Priority Health as well as first tier, downstream and related entries (FDR's).
Compliant operations and oversight of monitoring plan's pharmacy utilization management. Ensure staffing levels are sufficient to maintain service levels. Develop,implement and maintain performance tracking and trending tools to allow for daily monitoring of the team’s performance level for all functions to ensure that departmental, CMS, Medicaid, NCQA and PPACA standards are met.
Project Management. Effectively develop, prioritize and implement project plans as assigned by management.
Budget. Pharmacy Operations Budget. Develop and monitor operating budget for Pharmacy Operations and Pharmacy Utilization Management, manage the budget to meet or reduce operating margin goals
Contract management with Pharmacy Vendors (PBM, Specialty Pharmacy, Previous PBM, Prior-Authorization Software vendor and any other vendors as assigned by AVP Pharmacy Programs.) Ensure contract is operationalized and adhered to as written by vendors. Oversight of Performance Guarantees, collaborating with vendors to meet or exceed performance goals. Create corrective action plans as needed for return to service levels.
Qualifications
DoctorateofPharmacyDegree. Required
3 years of relevant experience Pharmacy Benefit Administration. Required
3 years of relevant experience in a leadership role. Required
3 years of relevant experience working in an organization of size and pharmacy benefit complexity comparable to Priority Health. Required
3 years of relevant experience Managing Pharmacy program operations and vendor programs. Required
LIC-Clinical Pharmacist - State Other than Michigan Upon Hire required Or
LIC-Clinical Pharmacist - State of Michigan Upon Hire required
Primary Location
SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids
Department Name
Pharmacy Executive - PH Managed Benefits
Employment Type
Full time
Shift
Day (United States of America)
Weekly Scheduled Hours
40
Hours of Work
8 a.m. to 5 p.m.
Days Worked
Monday to Friday
Weekend Frequency
N/A
CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
People are at the heart of everything we do, and the inspiration for our legacy of outstanding outcomes, innovation, strong community partnerships, philanthropy and transparency. Corewell Health is a not-for-profit health system that provides health care and coverage with an exceptional team of 65,000+ dedicated people—including more than 12,000 physicians and advanced practice providers and more than 15,500 nurses providing care and services in 21 hospitals, 300+ outpatient locations and several post-acute facilities—and Priority Health, a provider-sponsored health plan serving more than 1.3 million members. Through experience and collaboration, we are reimagining a better, more equitable model of health and wellness. For more information, visit corewellhealth.org.
