Fallon Health

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Government Programs Operational Pharmacist - Health Care

Government Programs Operational Pharmacist - Health Care

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About Fallon Health:

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.


Brief Summary of Purpose:

The Government Programs Pharmacist will:

  • Ensure compliance to all CMS, EOHHS regulations, and state mandates related to pharmacy
  • Develop and support implementation of product specific clinical and government programs designed to improve HEDIS and STAR measures
  • Oversee utilization management related to government programs


  • Implement pharmacy benefits and regulatory changes to ensure compliance with regulatory requirements
  • CMS CDE reporting requirements and monitoring
  • CMS/NCQA audits and Universe monitoring
  • Update to policies and procedures
  • CMS OMS reporting
  • CMS MTM Reporting and monitoring
  • Regulatory requirements and reporting updates (with IT assistance)
  • Medicare Star ratings
  • Medicare Quality reports and Initiatives
  • Website criteria updates and Medicare pharmacy description updates
  • PBM monitoring for Utilization Management functions and regulatory requirements Monitoring that Prior Authorization and Coverage Determinations are properly evaluated
  • Criteria posting for Provider website and update of criteria tracker – with Digital Content team
  • Review of CMS call letter and tech spec for FA, CD and MTM and P & P updates
  • CMS Data Validation (CDE, MTM)
  • Oversight of decision made on review of medication PA/exception requests, as well as completing data analysis and various clinical projects
  • Collaborate with the business to develop process changes to ensure compliance with regulatory changes related to Medicare Part D and EOHHS and state mandates
  • Read, interpret, summarize, and assess the impact on business operations of Medicare and/or accrediting body regulations, guidance, and communications
  • Develop corrective action plan responses when required
  • Support the administration of internal and external audits, CMS Complaint Tracking Module issues, the annual Part D application process, reporting requirements, and data validation audits
  • Support the testing and validation of the Medicare Prescription Drug Plan Finder, formulary, marketing materials, and the member portal
  • Provide training and presentations to internal departments on an as needed basis
  • Document and maintain project plans and status reports as related to the annual Part D implementation process, audits and other ad hoc initiative as needed
  • Participate in the oversight of subcontracted vendors to ensure compliance with Medicare and accrediting body requirements
  • Ensure adherence to EOHHS (MassHealth) clinical initiatives including but not limited to Hepatitis C, Pediatric Behavioral Health Medication Initiative, Opioid Overutilization Monitoring
  • Ensures compliance to ACO pharmacy initiatives related to quality, medication management and utilization review



PharmD preferred, but will consider an RPh with Managed Care/Regulatory experience.



Current License to practice as pharmacist in Massachusetts without restriction



5 years with at least three years in a managed care environment with Medicare and Medicaid

1-2 years professional experience practicing as a clinical pharmacist

Medicare Part D knowledge

CMS guidance around formulary and UM

Transition Fill

Calendar cycle of events

Negative change process

Part D vs part b vs. Excluded drugs

EGWP Specific Knowledge

Commercial benefit knowledge (for formulary wrap)

Audit experience

General knowledge of Coverage Determination, Appeals and Grievance process

Review/validation of test data

Proficient in Excel, Microsoft Word, Power Point and Outlook